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LIBRARY  OF 

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from: 

THE  CLINIC  PUBLISHING  COMPANY, 

CHICAGO. 


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COLPOPERINEORRHAPHY 

AND  THE  STRUCTURES  INVOLVED 


THE  VAGINA  AND  PERINEUM  AND  HOW 
TO  MEND  THEM 


BYRON  ROBINSON,  B.S.,M.D, 

Chicago,   III. 


Author  of  "Practical  Intestinal  Surg-er.v,"  "Landmarks  in  Gynecolog-y," 
"Life-size  Chart    of   the  S.vmpathetic    Nerve,"   "  The  Peri- 
toneum,     its      Histolog-.v      and      Physiolog-j." 
"The  Abdominal  Brain  and  Auto- 
matic   Visceral    Gan- 
fflia."  etc. 


Professor  in  Chicago  Post-Graduate  School  of  Gynecolog-y  and  Abdom- 
inal Surg-ery;  Professor  of  Gynecolog-y  and  Abdominal  Surg-ery 
in  the  Harvey   Medical   Colleg-e,   and    in   the  Illinois 
MedicalColleg-e;Gynecolog-ist  to  St.  Anthony's 
Hospital;  Consulting-  Surg-eon  to  the 
Mary  Thompson  Hospital  for 
"Women  and  Children. 


CHICAGO: 

THE  CLINIC  PUBLISHING  CO. 

1899. 


ENTERED,  ACCORDING  TO   THE  ACT  OF   CONGRESS,  IN  THE   YEAR   189C 

By  the  clinic  PUBLISHING  COMPANY, 

IN  THE  OFFICE  OF  THE  LIBRARIAN  OF  CONGRESS,  AT  WASHINGTON. 


CD 

cm 

•a: 


DEDICATION. 


This  monograph,  prepared  for  presentation  before 

my   fellows    of    the    American    Medical    Association 

(Denver,  June,  '98)  and  published  in   The  Journal  of 

the    American    Medical    Association,     is    respectfully 

dedicated    to  the  medical    profession  with  the  hope 

that  my  labors,  surgical  researches,  and  experiences 

as  herein  outlined  will  be  of  direct  interest  and  help 

to  them  and  indirect^,    through    them,   to   suffering 

and  needy  humanity. 

The  Author. 


PUBLISHER'S  PREFACE. 


We  have  taken  great  pleasure  in  reproducing  this 
book  from  the  pages  of  The  Journal  of  the  American 
Medical  Associatioii.  Like  everything  that  comes 
from  Dr.  Robinson's  pen  it  is  full  of  good  things  and 
evidences  an  amount  of  labor  that  few  are  willing  to 
give  to  the  work  they  undertake  to  do.  We  there- 
fore heartily  recommend  it  to  every  physician  who 
thinks  that  he  can  or  might  be  helped  in  the  treat- 
ment of  the  class  of  cases  to  which  it  refers.  The 
drawings  for  this  profusion  of  illustration  were  made 
from  life  during  the  process  of  the  author's  numerous 
operations  in  his  extensive  clinics,  and  are  as  true 
and  helpful  as  it  is  possible  for  such  cuts  to  be. 
These,  with  the  full  and  complete  text,  should  be  of 
great  help  to  those  who  have  not  reached  a  perfectly 
satisfactory  technique  of  their  own,  and  must  certainly 
be  of  interest  to  all. 

The  Clinic  Publishing  Co. 

Station  X,  Chicago. 


COLPOPERINEORRHAPHY  AND  THE 
STRUCTURES  INVOLVED. 


The  structures  involved  in  the  repair  of  a  defectivo 
perineum  are  muscles  and  fasciae.  The  operative  pro- 
cedure consists  in  denudation  with  coaptation  or  flap- 
splitting  methods.  Notwithstanding  the  successful 
claims  for  the  varied  surgical  methods  of  colpoper- 
ineorrhaphy  the  anatomical  basis  is  neither  generally 
nor  perfectly  understood.  It  is  probable,  however, 
that  the  essential  success  lies  in  the  reunion  of  the 
separated  levator  ani  muscle  by  means  of  its  fascise 
superior  and  inferior  with  some  other  fasciee,  and  also 
that  this  success  has  been  chiefly  due  to  deep  sutur- 
ing. The  object  of  this  essay  is  to  demonstrate  that 
the  chief  factor  in  successful  colpoperineorrhaphy  is 
the  restoration  by  the  aid  of  deep  sutures  of  the  fascise, 
especially  the  levator  ani  fasciae,  superior  and  inferior. 

The  muscles  of  the  pelvic  floor  may  be  divided  into 
two  classes:  a,  the  deep  layer — the  levator  ani  coccy- 
geus  and  pyriformis;  6,  the  superficial  layer — the 
transversus  perinei,  bulbo-cavemosus  and  sphincter 
ani  externus.  A  peculiar  characteristic  of  the  muscles 
of  the  pelvic  floor,  and  one  which  demands  respect  in 
colpoperineorrhaphy,  is  the  extensive  fascial  attach- 
ments of  one  or  both  ends  of  the  muscles.  The  levator 
ani,  the  bulbo-cavernosus  and  the  transversus  perinei 
have  a  fascial  attachment.  We  will  consider  in  detail 
the  muscles  and  fascise  involved  in  colpoperineor- 
rhaphy. The  basis  of  this  labor  is  a  careful  anatomic 
investigation  with  considerable  clinical  and  surgical 
experience. 


6  THE   VAGINA  AND   PERINEUM; 

THE  LEVATOR  ANI  MUSCLE. 

The  levator  ani  muscle  is  perhaps  the  most  difficult 
to  understand  as  regards  its  form,  insertion  and  func- 
tion. The  origin  of  the  muscle  is  sufficiently  plain, 
and  is  considered  established  by  anatomists.  Few 
agree  as  to  exact  insertion,  even  at  this  late  day,  and 
opinions  vary  as  to  the  exact  function,  form  and  in- 
sertion of  this  muscle.  My  own  investigations  demon- 
strate that  there  is  a  foundation  for  these  varied 
opinions. 

1.  The  insertion  and  origin  of  the  levator  ani  vary 
as^  to  the  extent  of  distinct  muscular  loops  which  em- 
brace the  rectum  and  vagina,  as  to  the  tendinous 
raphe  (between  muscle  loops  and  distal  ends  of  the 
coccyx),  also  regarding  the  precise  relation  to  the 
vaginal  wall,  whether  muscular  or  connective  tissue, 
and  also  as  regards  the  exact  relations  to  the  muscle 
of  the  lower  end  of  the  rectal  wall.  Moreover,  its 
partial  fascial  origin  and  insertion  is  sure  to  endow  the 
extremities  with  varying  appearances  as  to  the  length 
of  the  fascial  or  tendinous  conditions;  in  other  words 
the  distance  of  the  red  muscular  fibers  from  the 
extreme  origin  and  insertion  of  the  levator  ani  vary. 
Perhaps  this  variation  in  insertion  may  be  explained 
by  considering  the  levator  ani  as  a  rudimentary  mus- 
cle and  to  be  disappearing  with  the  tail.  Its  double 
fascial  accompaniments  complicate  its  origin  and 
insertion,  as  well  as  the  interpretation  of  its  function. 

2.  The  various  opinions  as  to  the  form  of  the  levator 
ani  are  explained  by  difPerences  as  regards  sex  idio- 
syncrasies of  individuals,  disturbances  from  gestation 
and  parturition,  variation  of  the  shape  of  the  pelvis 
and  fascial  insertions  and  attachments. 

3.  The  different  views  as  to  the  function  of  the 
levator  ani  lie  in  confusing  its  function  with  the  le- 
vator ani  fascia,  superior  and  inferior,  in  exaggerating 
its  size  and  attributing  to  it  function  and  utility  be- 


HOW  TO   MEND   THEM,  7 

longing  to  other  genital  supports.  It  ia  especially 
erroneously  inferred  that  a  muscle  will  act  as  a  con- 
tinuous tensionized  support  for  any  viscus.  The 
knowledge  of  the  levator  ani  muscle  is  fragmentary 
and  difficult  of  access.  Its  dissection  is  far  from  easy 
and  its  adjacent  relations  are  complicated.  The  mus- 
cle does  not  resemble  a  funnel  with  the  rectum  or 
vagina  at  the  bottom  or  apex,  but  is  more  similar  to 
a  sling,  a  flat  loop  or  a  horseshoe,  which  does  not  pull 
the  rectum  or  vagina  directly  upward,  but  draws  the 
two  canals  forward  and  upward  toward  the  pubic  cord. 

The  muscular  loop  of  the  levator  ani  muscle  resem- 
bles a  horse's  collar  encircling  the  rectum  or  the 
vagina.  In  the  female  it  vigorously  controls  two 
canals — rectum  and  yagina — yet  its  control  of  the 
vagina  depends  on  that  of  the  rectum.  The  rectum 
being  forced  forward  against  the  middle  of  the  pos- 
terior vaginal  wall  produces  the  H- shape  to  the  vagina. 
The  excess  of  vaginal  wall  is  compelled  to  fold  at  the 
sides  producing  the  upright  columns  of  the  H.  It  is 
very  thin.  In  an  excellent  specimen  which  I  dissected 
from  a  good- sized  woman  the  levator  ani  muscle  is  so 
thin  as  to  be  really  membranous,  and  the  muscular  band 
between  the  vagina  and  rectum  is  but  a  few  lines  in 
thickness.     It  is  really  a  pelvic  diaphragm. 

The  muscle  should  be  considered  as  to  its  origin, 
course  and  insertion. 

Origin. — The  levator  ani  muscle  arises:  from  bone, 
from  the  posterior  surface  of  the  pubis  and  ischial 
spine;  or  from  fascia,  arcus  tendineus  and  vesico- 
pubic ligament.  The  bony  origin  is  the  posterior 
surface  of  the  pubic  bone  and  ischial  spine.  The 
larger  portion  of  the  levator  ani  of  bony  origin  arises 
from  the  posterior  surface  of  the  pubis.  It  begins 
about  half  an  inch  from  the  symphysis  and  one  and 
one-half  to  two  inches  below  the  pubic  crest.  This 
point  of  origin  is  about  two  fingers  wide  or  one  and 


8 


THE   VAGINA   AND   PERINEUM; 


one-half  inches,  and  does  not  meet  its  fellow  of  the 
opposite  side,  one-half  to  one  inch  existing  between 
them  on  the  posterior  surface  of  the  pubis,  which  is 
filled  in  by  the  obturator  fascia.  The  bundle  of  mus- 
cles originating  on  the  posterior  surface  of  the  pubis 
passes  downward  and  backward  to  embrace  the  vagina 
and  rectum.  This  is  the  pubic  sling  or  horseshoe  loop, 


Fig.  1. — (Robinson-Scholer.)  This  cut  is  drawn  from  a  female  pelvis 
dissected  by  the  author  and  intended  to  show  the  muscular  floor  of  the 
pelvis  with  fascia  dissected  off.  1,1,  the  levator  ani  muscle;  2,  2.  the 
white  line  or  origin  of  the  levator  ani ;  8, 3,  the  obturator  internus  muscle ;, 
4,  4,  the  coccygeus  muscle :  5,  5,  the  pyriformis  muscle ;  6, 6,  the  inner  wall 
of  pelvis;  7, 7,  sacrum;  H,  H,  the  horse-shoe  loop  of  the  levator  ani  muscle, 
drawn  darker ;«8.  the  Y-shaped  urethra;  9.  the  vagina,  cut  close  to  the 
pelvic  floor,  whose  wall  does  not  flare  like  the  radial  wall,  10;  11, 11,  the 
obturator  nerves ;  12, 12,  inner  wall  of  pelvis ;  13,  pubic  crest ;  14, 14,  iliac 
fossa;  15,  last  (5th)  lumbar  vertebra. 

which  is  quite  thick  and  strong  in  some  cases,  and 
very  thin  and  membranous  in  others.  The  margin  of 
the  loop,  which  is  applied  against  the  sides  of  the 
vagina  and  rectum,  is  often  the  thickest  part  of  the 


HOW   TO   MEND   THEM.  9 

muscle.  The  muscular  bundles  of  the  horseshoe  loop 
join  those  of  the  opposite  side  of  the  levator  ani  pos- 
terior to  the  vagina  and  rectum  without  an  interven- 
ing perineal  tendon  or  raphe.  In  some  dissections  it 
is  absolutely  plain  that  no  tendinous  raphe  exists, 
while  in  others  it  can  not  be  told. 

The  smaller  portion  of  the  levator  ani  of  bony  origin 
is  from  the  ischial  spine  immediately  anterior  to  the 
origin  of  the  coccygeus  muscle.  Quite  a  distinct  strip 
one-fourth  to  one- half  inch  wide  comes  from  the 
ischial  spine,  and  can  be  plainly  followed  by  the  eye 
to  the  horseshoe  loop. 

The  ligamentous  origin  is  from  the  anterior  liga- 
ment of  the  bladder  (ligamentum  pubo-vesicale)  and 
from  the  arcus  tendineus  (white  line).     The  fibers  of 
the  levator  ani  which  arise  from  the  ligamentum  pubo- 
vesicale  are  of  little  practical  importance.     The  white 
line  extends  in  a  slightly  curved  direction  from  the 
posterior  lateral  surface  of  the  pubis,  over  the  obtura- 
tor foramen  to  the  spine  of  the  ischium.  The  anterior 
end  lies  two  and  three-fourths  inches  below  the  ileo- 
pectineal  line,  with  a  length  of  about  four  inches. 
The  white  line  (arcus  tendineus)  is  a  part  or  an  ex- 
tension of  the  anterior  true  ligament  of  the  bladder,  a 
thickening  of  the  levator  ani  fascia  superior.     In  the 
white  line,  the  muscular  fibers  arise  as  fine  tendinous 
bands,  and  may  show  their  reddish  muscular  nature 
at  the  white  line  or  a  short  distance  from  it.     The 
muscle  may  shade  into  a  flat  tendinous  layer  before  it 
reaches  the  white  line.     The  proximal  tendon  of  tke 
levator  ani  muscle  varies  much  as  to  its  relations  with 
the  white  line.     It  may  arise  below  it  as  well  as  from 
it.  ,  The  white  line  may  project  into  the  pelvis  as  a 
tendinous  fold,  and  be  capable  of  being  separated 
from  the  origiil  of  the  muscle. 

The  course  of  the  fibers  of  the  horseshoe  loop  of 
the   levator  ani  muscle  is  backward  and  downward 


10 


THE    VAGINA   AND   PERINEUM; 


in  two  fleshy  bundles,  the  smaller  to  the  side  and  pos- 
terior surface  of  the  vagina,  and  the  larger  to  the 
side  and  posterior  wall  of  the  rectum.  The  loops 
which  pass  along  the  sides  of  the  vagina  seem  to  be 
attached  to  the  vaginal  walls  by  connective  tissue 
only,  while  the  loops  of  muscular  fibers  which 
embrace  the  rectum  interweave   with   the  muscular 


jii^        '-  "  ->.- 


-»-  ■  -  -^^  "->^-"^~'  ^' 


Fig.  2.—(Robinsoii-8ch.oler.)  This  is  a  cut  drawn  from  a  female  pelvis 
dissected  by  the  author.  It  illustrates  the  inferior  surface  of  the  pelvic 
floor.  0_n  the  left  side  (m  the  fig.)  the  levator  ani  fascia  inferior  is  not 
^ssected  oft,  while  it  is  on  the  right  side,  showing  the  inferior  surface  of 
the  levator  am  muscle.  1, 1,  shows  the  levator  ani  muscle  with  its  parallel 
bundles;  2,  the  levator  ani  fascia  inferior;  3,3,  the  obturator  internus 
muscle;  4,  4,  the  coccygeus  muscle;  5,5.  the  gluteus  maximus;  6,  ano- 
coccygeal structure;  7,  7,  the  horse-shoe  loop  of  the  levator  ani,  showing 
some  muscular  bundles  coursing  between  rectum  and  vagina.  It  is  not  so 
large  on  the  inferior  surface  as  it  is  on  the  superior  surface  of  the  pelvic 
V?^I'  .81  urethra;  9,  vagina;  10,  anus  flaring;  11,  pubic  arch;  12,  sacrum; 
13,  flaring  ilium. 

bundles  of  the  rectal  wall,  forming  a  strong  connec- 
tion. The  part  interwoven  in  the  rectal  wall  acts  as 
an  elevator.     It  would  appear  that  in  some  oases  the 


HOW   TO    MEND   THEM.  11 

loops  of  the  levator  ani  interweave  with  the  mus- 
cular fibers  in  the  wall  of  the  vagina.  The  part  of 
the  levator  ani  which  passes  between  the  vagina  and 
rectum  is  a  small,  thin  band,  one-sixth  to  one-eighth 
of  an  inch  in  width,  which  arises  from  the  external 
part  of  the  pubic  origin  and  passes  over  the  large 
l)elly  of  the  muscle  to  gain  the  rectovaginal  situa- 
tion. Its  relations  to  the  wall  of  the  vagina  are  very 
close  if  not  interwoven  with  its  fibers. 

The  part  of  the  muscle  of  fascial  origin  which 
arises  from  the  white  line,  passes  backward  and  down- 
ward, becoming  part  of  the  levator  loop  and  partly 
inserted  in  the  tendinous  perineal  raphe  and  the 
last  bone  of  the  coccyx.  Many  of  these  fibers  pass 
downward  in  a  curve,  and  when  near  the  median  raphe 
they  turn  acutely  backward  to  become  inserted  into 
the  coccyx.  A  few  of  the  muscular  fibers  arising 
from  the  white  line,  as  well  as  from  the  horseshoe- 
shaped  loop,  together  with  some  from  the  ischial 
spine,  embrace  the  rectum.  The  part  of  the  levator 
ani  arising  from  the  ischial  spine  becomes  inserted 
chiefly  in  the  coccyx.  Yet  one  may  observe  one- 
fourth  of  an  inch  in  width  pass  around  the  rectum 
with  no  intervening  tendinous  raphe. 

The  part  of  the  levator  ani  muscle  of  special  inter- 
est to  the  gynecologist  is  the  two-fingers  wide,  horse- 
shoe-shaped sling  which  arises  from  the  posterior 
surface  of  the  pubis  and  passes  backward  and  down- 
ward to  embrace  both  rectum  and  vagina.  It  is  the 
belly  of  this  loop  which  gives  the  rectum  its  for- 
ward curve  just  before  the  anal  end  is  turned  back- 
ward. It  is  the  sphincter  portion  of  the  muscle.  It 
is  this  part  of  the  muscle  which  becomes  hypertro- 
phied  in  vaginismus.  It  is  the  portion  of  the  muscle 
torn  and  separated  in  lacerated  perineum.  It  is  the 
portion  of  the  muscle  which  retards  labor,  creates 
vaginal  spasm  and  may  prevent  coition,  and  in  rare 


12 


THE   VAGINA   AND    PEEINEUM; 


Fig.  3. — CAuthor. )  This  figure  I  drew  semi-diagramatically  to  illustrate 
the  general  view  of  the  pelvic  outlet.  1,  clitoris ;  2,  crura  clitoridis ;  3, 
erecto  clitoridis  muscle ;  4,  urethra ;  5.  orifice  of  vagina ;  6,  bulbo-eavern- 
osus  muscle ;  7,  yulvo- vaginal  glands  (of  Duverny,  of  Barthalin,  of  Tiede- 
man) ;  8,  posterior  vaginal  commissure ;  9,  transversus  perinei  muscles ; 
10,  obturator  internus  muscle;  11,  anus;  12,  sphincter  ani  externus;  13, 
coccyx;  14,  levator  ani  muscle;  15,  great  sacrosCiatic  ligament;  16,  the 
bulb  of  the  vagina ;  17,  deep  layer  of  superficial  perineal  fascia. 


HOW   TO   MEND   THEM.  13 

cases  prevents  the  penis  from  escaping  until  relaxed 
by   an   anesthetic.     In   most   cases   the   levator   ani 
behind  the  rectum  may  be  divided  into  three  quite  dis- 
tinct parts,  viz.,  a,  the  part  which  is  connected  to  the 
last  bone  and  fascia  of  the  coccyx.     The  fibers  accom- 
panying this  portion  of  the  muscle  originate  chiefly 
from  the  posterior  end  of  the  white  line  or  at  the 
ischial  spine,     h.  A  portion  of  the  muscle  forms  a 
median  tendinous   raphe  for  about  one-third  of  an 
inch   immediately   in  front   of   the   coccyx,     c.  The 
portion  of  the  muscle  immediately  behind  the  anus, 
about  three-fourths  of  an  inch  wide,  has  no  interven- 
ing tendinous  raphe  (not  always  distinct)  and  con- 
sists of  the  belly  of  the  loops  which  originate  and 
insert   on   the   posterior    pubic    surface.      In   other 
words,  the  muscular  fibers  of  each  side  anastomose, 
forming  the  horseshoe- shaped  loop,  with   no  inter- 
vening tendinous  raphe.     Some  of  the  loops  inter- 
twine with  those  of  the  sphincter  ani,  which  pass 
back  to  the  tip  of  the  coccyx,  also  some  of  the  mus- 
cular  fibers  of  the  sphincter  ani  externus  are  con- 
tinuous with  the  loops  of  the  levator  ani.     The  fibers 
of  the   levator  ani  originating  from  the  white  line 
pass  backward  and  downward,  but  on  arriving  at  the 
median  raphe,  many  of  the  fibers  turn  sharply  back- 
ward to  be  inserted  into  the  coccyx,  and  soon  become 
tendinous.      The  levator  ani  fascia  superior  is    not 
very  intimately  attached  to  the  muscle,  and  may  be 
compared  to  the  fascia  transversalis.     The  levator  ani 
fascia  inferior  is  adherent  to  the  muscle. 

Deductions  in  regard  to  the  levator  ani  muscle  may 
be  numerous.  Certain  practical  considerations  may 
be  drawn  from  a  careful  study  by  dissection  and  in 
gynecologic  practice.  As  it  was  originally  a  muscle 
of  the  tail  it  is  becoming  vestigial  in  man,  shown  by 
its  fascial  connections.  From  the  origin,  course  and 
insertion  of  the  levator  ani  muscle,  it  must  be  viewed 


14  THE  VAGINA  AND  PERINEUM; 

as  the  all-important  muscle  of  the  pelvic  floor. 
The  levator  ani  fascia  superior  is  the  real  visceral 
support.  I  think  it  was  Dr.  Meyers,  a  German  physi- 
cian, who  first  happily  named  it  the  pelvic  diaphragm. 
In  many  subjects  it  is  membranous.     The  normal 


Fig.  4,— (Luschka,  1864,)  Redrawn  and  modified  represents  a  view  of 
the  levator  ani  muscle.  L,  L,  the  modification  of  Luschka's  figure  con- 
sists in  magnifying  the  rectal  curve  made  by  the  levator  ani  muscle ;  C,  is 
a  continuation  of  the  levator  ani  muscle  backward,  drawn  lightly ;  V, 
vagina.  ^  The  grip  on  the  rectum  by  the  horse-shoe  sling  of  the  levator  ia 
here  plain.    The  levator  ani  fascia  inferior,  p,  is  shown  rolled  up. 


HOW   TO   MEND    THEM.  15 

muscle  has  the  shape  of  a  boat,  and  when  this  boat- 
shape  becomes  cone-shaped,  the  pelvic  floor  is  im- 
paired.  The  levator  ani  is  composed  of  many  mus- 
cular bundles  coursing  chiefly  parallel  to  each  other, 
but  also  at  varying  distances.  The  bundles  are 
flat,  ribbon-like,  and  of  a  bright  red  color.  The 
bundles  of  muscular  fibers  are  held  at  greater  or  less 
distance  from  one  another  by  collections  of  fat  or 
connective  tissue  in  varying  degrees.  Fenestra  or 
apertures  are  commonly  observed  between  the  mus- 
cular loops.  The  capacity  of  the  bundles  of  the 
levator  ani  muscle  to  separate  and  reunite  without 
injury,  serves  a  useful  purpose  in  labor,  when  rapid 
and  wide  distention  of  the  pelvic  floor  may  occur. 
Too  many  figures  illustrate  the  muscle  as  a  distinct 
plane  with  no  parallel  gaps  between  the  bundles. 

The  levator  ani  (the  deep  muscular  layer  of  the 
pelvis)  is  connected  to  the  external  sphincter  ani  of 
the  rectum  and  vagina  (the  superficial  muscular  layer 
of  the  pelvis)  and  by  this  muscular  connection  to 
the  perineal  body  (the  punctum  fixum),  the  deep  and 
superficial  muscular  layers  of  the  pelvis  are  brought 
into  intimate  relations  of  much  utility.  A  few  fibers 
are  lost  in  the  perineal  body.  The  levator  ani  is  in 
closer  organic  relation  with  the  rectum  than  Ihe 
vagina,  because  the  rectum  requires  more  frequent 
and  perfect  evacuations  than  the  vagina.  It  is  chiefly 
a  sphincter  muscle.  The  weakness  of  its  origin, 
insertion  and  direction  of  its  fibers  is  in  accordance 
with  its  fading  out  of  existence. 

The  forward  curve  of  the  rectum  is  due  to  the 
horseshoe-shaped  loop  of  the  levator  ani,  which  orig- 
inates chiefly  from  the  posterior  surface  of  the  pubis. 
By  the  contraction  of  the  lower,  stronger  fibers  of  the 
levator,  the  lower  portion  of  the  rectum  is  forced 
against  the  perineal  body,  which  compels  the  anus  to 
turn  backward  and  to  evacuate  its  contents. 


16 


THE  VAGINA  AND   PERINEUM; 


The  levator  ani,  on  account  of  its  shape  and  size, 
leaves  deficiencies  in  the  pelvic  floor,  which  are  filled 
in  front  by  the  bulbo-cavernosus  and  behind  by  the 
coccygeus  muscle,  its  continuation  backward. 

The  palpable  rounded  edge  of  the  levator  ani  lies 
three-quarters  of  an  inch  above  the  anus  and  three- 
quarters  of  an  inch  above  the  vaginal  opening,  making 


Fig.  5.— (Dickinson,  1889.)  The  levator  ani  as  seen  through  the  skin; 
the  outlet  of  the  pelvis  is  dotted  and  the  direction  and  course  of  the  chief 
muscular  bundles  of  the  levator  ani  marked  out. 

the  muscle,  in  fact,  a  regulator  of  the  external  open- 
ings of  these  two  canals.  Normally  the  orifices  of  the 
canals  are  always  closed.  They  remain  open  only  by 
internal  or  external  force  or  from  trauma. 

The  levator  ani  will  lift  from  five  to  twenty  pounds, 
averaging  about   ten  as   noted  by   Dickinson.     Its 


HOW   TO   MEND   THEM.  17 

strength  soon  tires  out  assistants  in  vaginal  hysterec- 
tomy. From  its  insertion  into  the  perineal  body  the 
external  sphincter,  post-rectal  raphe  and  coccyx,  it 
draws  forward  the  post- vaginal  structures  of  the  pelvic 
floor.  In  the  excellent  work  of  Savage,  he  names  the 
portion  from  the  principal  bony  origin,  pubo-coccy- 
geus.  This  is  erroneous,  as  these  loops  do  not  pass  as 
far  back  as  the  coccyx — <io  not  even  come  in  contact 
with  it.  The  levator  lifts  the  rectum  and  vagina  for- 
ward and  upward  to  the  pubic  arch.  The  muscle  has 
but  limited  influence  on  the  sides  of  the  rectum.  The 
muscular  fibers  composing  the  horseshoe  loop  exercise 
the  chief  influence  over  the  rectum,  while  the  portion 
of  the  muscle  arising  from  the  white  line  (fascia) 
serves  its  purpose  by  holding  the  pelvic  diaphragm 
in  relation  prepared  for  any  immediate  action,  with 
its  superior  and  inferior  fascia  it  makes  a  tense  floor 
for  the  superimposed  viscera. 

The  levator  ani  fascia  superior  and  inferior  lends 
the  muscle  its  greatest  utility  by  increasing  its  strength 
and  also  producing  harmonious  action  in  its  func- 
tion. The  horseshoe  sling  is  inseparably  blended 
with  the  sphincter  ani  externus.  The  levator  ani  pro- 
duces the  H-shaped  condition  of  the  vagina  and  its 
puckered  or  constricted  appearance  at  the  orifice. 
The  muscle  becomes  hypertrophied  during  pregnancy 
and  vaginismus.  It  resists  the  head  in  labor  to  a  sur- 
prising degree.  It  may  be  easily  observed  in  slow 
labor,  when,  if  small  forceps  sufficient  to  overcome 
the  tension  of  the  muscle  be  applied,  labor  proceeds 
rapidly. 

The  comparison  of  the  diaphragm  and  levator  ani, 
as  to  the  capacity  for  strength,  is  in  favor  of  the  leva- 
tor ani.  Its  strength  varies  much  in  different  sub- 
jects. The  best  descriptions  of  the  levator  ani  muscle 
are  given  by  Henle,  Luschka,  Testut  and  Lesshaft. 
Hart  and  Dickinson  have  made  excellent  studies  on 


18 


THE  VAGINA  AND  PERINEUM; 


this  muscle.  Browning  wrote  an  interesting  article 
on  the  subject.  The  levator  ani  may  be  a  rudimentary 
muscle,  disappearing  with  the  tail  and  in  the  evolu- 
tionary process  of  an  erect  attitude.  This  view  may 
arise  from  the  weakness  of  its  origin,  the  direction  of 
its  fibers  and  insertion,  as  well  as  the  requirement  of 
the  double  fasciae.    It  is  unphysiologio  for  a  muscle 


Fig.  6.— (Varnier,  after  Dickinson.)  The  distended  levator  ani.  V. 
bladder;  s,  p,  symphysis;  c,  clitoris;  c,  v,  constrictor  of  the  vulva;  F, 
fonrchette ;  P,  A,  anterior  perineum ;  A.  O,  anus ;  P,  P,  posterior  peri- 
neum ;  C,  R,  coccyx ;  P,  S.  point  of  sacrum ;  R,  R,  R,  is  on  the  muscle  with 
its  separated  bundles,  the  middle  R  is  on  the  strongest  bundle.  In  this 
figure  we  observe  how  the  muscle  can  save  itself  from  rupture  by  the 
separation  of  its  various  fasciculi.  It  yields  better  than  if  it  were  in  one 
connected  sheath. 

to  produce  constant  support,  hence  the  levator  ani 
can  not  be  considered  a  support  for  the  viscera;  it  is 
rather  a  sphincter  muscle. 

The  levator  ani  muscle  is  analogous  to  the  buccina- 
tor muscle.   Perhaps  from  an  evolutionary  standpoint 


HOW   TO   MEND   THEM.  19 

we  may  look  on  the  levator  ani  as  having  three  func- 
tions, viz.:  a,  of  a  sphincter;  h,  of  an  elevator;  and 
c,  of  a  tensor  of  the  levator  ani  fascia,  superior  and 
inferior. 

As  proof  that  the  levator  ani  is  a  sphincter,  one 
need  only  introduce  the  finger  into  the  vagina  and 
request  the  subject  to  contract  the  muscle.  Cruveil- 
hier,  Henle,  Lesshaft  and  Budge  insist  that  the  leva- 
tor ani  is  a  sphincter  of  the  anus  and  lower  rectum 
chiefly,  and  not  an  elevator.  That  this  muscle  is  an 
elevator  one  need  only  dissect  it  to  find  the  muscle 
ending  definitely  in  the  walls  of  the  rectum,  and  such 
terminating  fibers,  when  in  action,  could  only  elevate 
the  rectum.  The  horse  in  defecation  illustrates  that 
the  levator  ani  is  an  elevator,  as  the  rectal  wall  is 
elevated,  the  rectal  mucosa  everted  and  completely 
evacuated.  As  an  elevator,  it  resists  intra-abdominal 
pressure. 

The  levator  ani  appears  as  well  developed  in  the 
male  as  the  female,  and  hence  labor  does  not  appear 
to  develop  it.  The  levator  ani  muscle  is  greater  in 
those  animals  with  a  tail,  and  originally  its  chief  func- 
tion was  to  aid  in  managing  the  tail,  from  which  it 
would  appear  that  as  a  tensor  of  the  levator  ani  fascia 
superior  and  inferior,  these  fibers  take  an  active  part. 
They  originate  at  a  definite  fixed  point,  lose  them- 
selves between  the  fascial  blades  and  do  not  reach 
rectal  or  vaginal  walls.  When  a  muscular  fiber  neither 
goes  to  the  rectum  nor  ends  in  its  wall,  it  will  not  act 
as  a  sphincter,  nor  as  an  elevator. 

Lesshaft  and  Roux  divide  the  levator  ani  into  two 
layers,  viz.,  a,  the  inner  layer,  which  is  an  elevator, 
and  6,  the  outer  layer,  which  is  a  sphincter. 

THE  INTERNAL   PELVIC  FASCIA. 

The  internal  fascia  of  the  lesser  pelvis  has  a  poor 
literature,  and  is  not  often  described.    As  the  pelvic 


20 


THE  VAGINA  AND  PERINEUM; 


fascia  has  much  to  do  with  the  permanent  results  of 
the  flap  or  any  perineal  operation,  I  will  write  of  it 
somewhat  in  detail. 

The  fascia  of  the  greater  pelvis,  or  that  fascia  lying 
superior  to  the  ileopectineal  line,  is  not  here  con- 
sidered. The  fasciae,  the  planes  of  strong,  fibrous 
tissue  here  under  consideration,  lie  below  the  ileo- 
pectineal line. 


^  Fig.  7.— (Robinson-Scholor.)  A  diagram  to  illustrate  the  pelvic  fascia, 
with  a  new  nomenclature  of  same.  1,  1,  white  line;  2,  2,  origin  of  trans- 
versalis  and  iliac  fascia  at  the  iliac  crest ;  3, 3,  levator  ani  fascia  superior; 
4. 4,  levator  ani  fascia  inferior;  5,5,  Alcock's  canal;  6,6, obturator intemus 
muscle ;  7,  7,  levator  ani  muscle ;  8,  vagina  or  rectum ;  9,  external  sphincter ; 
10. 10,  ileopectineal  line ;  11, 11,  origin  of  levator  ani  fascia  superior ;  12, 12, 
beginning  of  obturator  fascia  inferior ;  13,  IS,  transversalis  fascia ;  14,  14, 
iliac  muscle;  15, 15,  iliac  fascia;  16, 16,  obturator  fascia  superior;  17,  17, 
ending  of  obturator  fascia  inferior  on  the  ischial  tuberosity. 

As  a  teacher  of  anatomy,  I  have  always  maintained 
that  a  fascia  should  be  named  according  to  the  muscle 
or  other  structure  with  which  it  is  in  the  most  inti- 


HOW   TO   MEND   THEM.  21 

mate  relation.  I  shall  therefore  apply  this  simple 
nomenclature  to  the  fascia  in  the  pelvis. 

The  fascia  covering  the  obturator  intemus  muscle 
will  be  termed  the  obturator  fascia.  As  this  fascia 
is  divided  by  the  white  line  extending  from  the  poste- 
rior surface  of  the  pubis  to  the  ischial  spine,  we  will 
call  that  portion  of  the  fascia  above  the  white  line 
the  obturator  fascia  superior,  and  that  portion  of  the 
fascia  below  the  white  line  the  obturator  fascia  infe- 
rior. The  fascia  above  the  levator  ani,  originally 
named  by  Tyrrell  the  rectovesicale,  and  by  Carcassone 
the  pelvic  aponeurosis,  by  others  the  vesical  layer  of 
the  pelvic  fascia,  we  will  name  the  levator  ani  fascia 
superior,  and  that  part  of  the  fascia  below  the  levator 
ani,  the  levator  ani  fascia  inferior.  The  fascia  cover- 
ing the  coccygeal  and  pyriformis  muscles  will  be 
named  after  those  muscles.  The  fascia  covering  the 
sacrum  very  naturally  takes  the  name  of  the  sacral 
fascia.  The  internal  fascia  of  the  lesser  pelvis  extends 
from  the  ileopectineal  line  on  either  side  to  the  median 
raphe  of  the  pelvic  floor.  It  not  only  lines  the  pelvic 
walls  and  floor,  but  enters  into  intimate  relations  with 
the  pelvic  viscera.  It  is  a  strong,  shiny,  fibrous  mem- 
brane, possessing  a  very  varying  quantity  and  quality. 
In  a  certain  sense  the  fascia  of  the  lesser  pelvis  should 
be  treated  as  an  independent  structure,  and  not  as  a 
continuation  of  the  iliac  transversalis  or  other  fasciae. 
The  ileopectineal  line  marks  an  absolute  division  be- 
tween the  iliac  and  obturator  fascia. 

The  simplest  plan  is  to  describe  the  obturator  fascia 
superior  and  inferior  and  to  consider  the  obturator 
fascia  as  distinctly  belonging  to  the  obturator  (inter- 
nus)  muscle,  subsequently  to  consider  the  fascia  of 
the  levator  ani  superior  and  inferior,  with  a  lesser  con- 
sideration of  the  coccygeus,  pyriformis  and  sacral  fas- 
ciae. The  fasciae  lining  the  lesser  pelvis  are  intimately 
connected  with  their  respective  associated  muscles  and 


22 


THE   VAGINA  AND   PERINEUM; 


structures  by  strong  connective  tissue.  The  connec- 
tion of  the  fascise  with  the  peritoneum  is  not  intimate, 
a  thick,  loose  layer  of  connective  tissue,  richly  laden 
with  fat  lobules,  lies  between  the  peritoneum  and  the 
fasciae  lining  the  lesser  pelvis.  This  loose  connection 
of  pelvic  peritoneum  and  pelvic  f ascise  allows  the  easy 
and  rapid  spread  of  pelvic  abscesses  between  the  pel- 
vic fasciae  and  the  peritoneum  in  the  subperitoneal 
tissue. 


Fig.  8.— (Ranney.)  Diagram  of  the  fascia  of  the  pelvic  floor  in  a  mesial 
section.  It  illustrates  the  levator  ani  fascia  superior  and  inferior  above 
and  below  the  levator  ani  muscle.  T,  L,  triangular  ligament;  P,  F,  two 
layers  of  superficial  perineal  fascia.  Observe  that  in  the  anterior  trian- 
gular perineal  space  there  are  five  layers  of  fasciae,  viz. :  1,  superficial 
layer  of  perineal  fascia ;  2,  deep  layer  of  superficial  perineal  fascia ;  3, 
triangular  ligament,  outer  layer ;  4,  triangular  ligament,  inner  layer ;  5, 
levator  ani  fascia  siiperior.  In  the  posterior  perineal  space  there  are  two 
layers  of  fascia— the  levator  ani  fascia  superior  and  the  levator  ani  fascia 
inferior. 

The  obturator  internus  fascia  surrounds  the  obtu- 
rator muscle  at  its  origin,  from  the  lateral  pelvic  sur- 
face of  the  innominate  bone,  and  is  the  special  fascia 
of  the  obturator  internus  muscle.  It  is  attached  for 
a  considerable  distance  to  the  iliac  portions  of  the 


HOW   TO   MEXD   THEM.  23 

brim.  At  this  point  the  obturator  becomes  attached 
to  the  upper  border  of  the  obturator  membrane.  In 
front,  the  attached  line  of  the  fascia  passes  below  the 
ileopectineal  line  to  allow  the  obturator  vessels  and 
the  nerve  to  enter  the  obturator  foramen  or  canal. 
This  portion  is  fixed  to  the  periosteum  and  appears  as 
an  independent  organ.  In  front  it  is  attached  to  the 
body  of  the  pubis  and  along  the  upper  margin  of  the 
obturator  foramen  by  an  oblique  line,  to  a  point  about 
one- half  an  inch  below  the  symphysis.  Where  the 
fascia  dips  under  to  allow  the  passage  of  the  obturator 
vessels  and  nerves  it  is  firmly  attached  to  the  perios- 
teum and  nerves  by  strong  tendinous  fibers.  Poste- 
riorly, it  is  attached  to  the  anterior  surface  of  the 
great  sacrosciatic  ligament  and  the  anterior  margin  of 
the  great  sacrosciatic  notch.  Inferiorly,  the  fascia  is 
attached  to  the  margin  of  the  obturator  foramen  of 
the  descending  ramus  of  the  pubis,  and  it  joins  the 
falciform  process  of  the  great  sacrosciatic  ligament, 
which  firmly  connects  it  to  the  inner  border  of  the 
ischium  and  its  ascending  ramus. 

With  a  firm  insertion  in  the  ileopectineal  line,  the 
anterior  border  of  the  great  sacrosciatic  foramen,  the 
anterior  and  inferior  margin  of  the  obturator  foramen 
and  to  the  edge  of  the  falciform  process  of  thjB  great 
sacrosciatic  ligament,  the  obturator  fascia  becomes  a 
fixed,  strong,  thick,  fibrous  membrane,  in  relation 
superiorly  with  the  obturator  nerve  and  vessels  and 
inferiorly  with  the  internal  pudic  vessels  and  nerves 
— Alcock's  canal.  It  has  intimate  attachments  to  the 
obturator  internus  muscle  above,  but  is  quite  loose 
below. 

The  obturator  fascia  we  divide  into  two  portions, 
superior  and  inferior.  The  obturator  fascia  superior 
is  that  portion  above  the  white  line  or  arcus  tendineus. 
It  looks  into  the  pelvic  cavity  from  the  lateral  aspect 
and  is  covered  by  peritoneum.     The  peritoneum  and 


24  THE  VAGINA  AND  PERINEUM; 

obturator  fascia  superior  are  separated  by  consider- 
able loose,  fatless,  snow-white  connective  tissue,  com- 
posed of  many  shiny,  thin,  cleavable  planes,  which 
become  easily  dissected  by  the  progress  of  pelvic 
abscesses. 

The  structures  of  importance  which  pass  over  the 
internal  face  of  the  obturator  fascia  superior  just  be- 
low the  ileopectineal  line  are  the  obturator  vessels  and 
nerves.  These  structures  are  liable  to  be  injured  by 
the  head  soon  after  its  engagement  by  the  brim  or 
fixed  bony  ring  of  the  pelvis.  The  obturator  fascia 
superior  has  a  surface  of  about  ten  square  inches. 

The  obturator  fascia  inferior  is  that  portion  below 
'the  arcus  tendineus  or  white  line.  It  looks  internally 
into  the  ischiorectal  fossa  and  externally  toward  the 
obturator  internus  muscle.  It  forms  the  external 
boundary  of  the  ischiorectal  fossa.  At  the  lower  part 
of  the  ischiorectal  fossa  about  an  inch  above  the 
tuberosity  of  the  ischium  the  obturator  fascia  plane& 
become  separated,  producing  a  sheath  —  Alcock'& 
Canal  —  for  the  transmission  of  the  pubic  vessels  and 
nerves.  The  obturator  fascia  inferior  has  a  surface 
of  some  five  square  inches,  one-half  the  size  of  the  ob- 
turator fascia  superior. 

At  the  lesser  sciatic  notch  the  obturator  fascia 
passes  out  of  the  pelvis  with  the  muscles  and  gains  the 
postero-femoral  regions  of  the  thigh.  The  obturator 
fascia  is  inserted  into  the  ramus  of  the  ischium  and 
pubis,  where  it  passes  on  and  blends  with  the  triangu- 
lar ligament  of  the  urethra,  hence  the  triangular  liga- 
ment is  a  continuation  of  the  obturator  fascia  from 
each  side. 

The  arcus  tendineus  or  white  line  appears  as  an 
aggregation  of  tendinous  fibers  of  the  obturator 
fascia.  It  extends  from  the  posterior  surface  of  the 
pubis  to  the  spine  of  the  ischium.  It  possesses  a 
gentle  curve  with  its  concavity  upward.     The  whit© 


HOW   TO   MEND   THEM.  25 

line  gives  origin  to  that  part  of  the  levator  ani  mus- 
cle which  arises  between  the  lower  posterior  surface 
of  the  pubis  and  ischial  spine.  The  white  line  arises 
out  of  the  ligaments  of  the  bladder;  a  thickened  por- 
tion of  the  obturator  fascia  is  the  line  of  origin  of  two 
planes  of  fascise.  The  upper  plane  I  call  the  levator 
ani  fascia  superior,  and  the  lower  plane  the  levator 
ani  fascia  inferior.  The  white  line  varies  in  thickness 
in  individuals — generally  is  one-sixth  of  an  inch  in 
thickness  in  the  middle,  but  its  greatest  strength  and 
width  is  at  the  anterior  end,  where  it  assumes  inti- 
mate relations  with  the  pubovesical  ligaments.  In 
women  the  white  line  is  about  four  inches  long.  Its  ori- 
gin at  the  pubis  may  be  chiefly  from  the  anterior  and 
lateral  (true)  ligaments  of  the  bladder.  The  white 
line  allows  considerable  elasticity.  It  is  quite  firmly 
fixed  at  the  anterior  end,  and  definitely  at  the  poste- 
rior end,  but,  like  a  long,  tight  rope,  allows  consider- 
able range  of  motion  and  sagging  in  the  middle. 

The  levator  ani  fascia  superior  (rectovesical  fascia 
of  Tyrell,  rectovesical  aponeurosis  of  Carcassone  or 
visceral  layer  of  the  pelvic  fascia)  arises  from  the  white 
line  and  passing  inward  forms  the  floor  of  the  pelvis. 
The  levator  ani  fascia  superior,  as  its  name  implies, 
covers  the  superior  surface  of  the  levator  ani  muscle. 
The  fascia  finally  loses  itself  in  the  median  raphe  be- 
hind the  rectum  in  the  rectal,  vaginal  and  vesical  walls, 
and  in  the  anterior  and  lateral  ligaments  of  the  blad- 
der. From  this  relation,  the  levator  ani  fascia  supe- 
rior becomes  of  significant  interest  in  perineorrhaphy. 
Anteriorly  it  is  remarkably  strong  and  short,  being 
attached  to  the  back  of  the  pubis  above  the  obturator 
fascia,  from  which  it  is  separated  by  the  origin  of  the 
levator  ani  muscle;  the  levator  ani  fascia  superior,  the 
levator  ani  muscle  and  the  obturator  fascia  being  all 
three  closely  adherent  to  the  pubic  bone  and  to  each 
other. 


26  THE   VAGINA   AND   PERINEUM; 

If  one  carefully  removes  the  peritoneum  and  loose 
subperitoneal  tissue  the  levator  ani  fascia  superior 
may  be  plainly  seen  stretching  from  the  white  line  to 
the  bladder,  vagina  and  rectum.  It  may  be  stripped 
off  the  levator  ani  muscle  in  several  thin,  cleavable 
planes.  It  is  reflected  on  the  bladder  forming  the 
anterior  true  and  lateral  true  ligament  of  the  bladder, 
however  the  lateral  ligaments  of  the  bladder  may  be 
assisted  by  ligaments  from  the  vagina.  The '  levator 
ani  fascia  superior  begins  its  anterior  attachments  at 
the  lower  border  of  the  symphysis,  continues  then 
along  the  white  line  laterally  to  the  ischial  spine,  con- 
tinues from  the  ischial  spine  on  the  superior  surface 
of  the  levator  ani  muscle  to  the  median  raphe.  The 
levator  ani  fascia  superior  covers  an  area  of  about  six 
square  inches  on  each  side  of  the  median  line  of  the 
pelvis. 

The  levator  ani  fascia  superior  may  be  divided  into 
the  anterior  or  vesical  portion,  the  vaginal  portion  and 
the  rectal  portion. 

The  vesical  portion  of  the  levator  ani  fascia  supe- 
rior is  reflected  from  the  pubis  to  the  neck  of  the 
bladder,  forming  the  anterior  true  ligaments  of  the 
bladder  and  part  of  the  lateral  ligaments.  The  vesi- 
cal portion  is  very  thick  and  strong,  even  tendinous. 
It  is  reflected  from  the  pubis  in  an  arched  manner. 
The  vaginal  portion  of  the  levator  ani  fascia  superior 
is  analogous  to  that  which  surrounds  the  prostate  in 
the  male.  In  the  male,  the  prostate  gland  and  vesi- 
culse  seminales  are  surrounded  by  a  strong  capsule 
derived  from  levator  ani  fascia  superior.  This  por- 
tion of  fascia  surrounds  the  vagina  in  the  female,  in- 
cluding the  large  venous  plexuses. 

The  vaginal  portion  is  endowed  with  considerable 
strength  and  it  becomes  blended  with  and  is  lost  on 
the  vaginal  wall.  The  rectal  portion  of  the  levator 
ani  fascia  superior  passes  to  the  rectal  wall,  becom- 


HOW   TO   MEND   THEM.  27 

ing  continuous  with  the  fibers  and  blending  with  it. 
There  is  a  strong  fillet  passing  between  the  rectal  and 
vaginal  canal.  The  part  of  this  fascia  which  passes 
to  the  rectal  wall,  has  been  termed  the  ligament  of 
the  rectum.  This  fascia  forms  a  strong  support  to 
the  muscular  wall  of  the  rectum. 

It  is  not  an  argument  very  rich  in  facts  to  say  that 
the  perineal  body  is  to  fill  in  the  space  in  that  region. 
It  serves  as  an  attachment  for  one  end  of  the  levator 
ani  muscle.  A  subject  which  I  have  not  found  men- 
tioned in  the  books  is  that  in  many  parts  the  fascia 
of  the  pelvis  consists  of  many  distinctly  defined 
layers,  which  can  be  cleaved  from  each  other.  For 
example,  the  fascia  over  the  coccygeal  muscle  may 
be  cleaved  off  in  several  layers,  and  the  same  may  be 
said, — but  not  to  such  a  degree — of  the  levator  ani 
superior.  Several  thin,  transparent  planes  of  fascia 
may  be  cleaved  off  of  the  obturator  fascia  superior. 
Even  the  levator  ani  fascia  inferior,  which  is  very  thin 
and  compact,  may  be  cleaved  into  two  or  more  planes. 
The  obturator  fascia  inferior  is  a  very  powerful 
fibrous  plane  of  fascia  and  may  be  cleaved  on  each 
side  into  thin  planes  but  the  central  plane  is  a  thick, 
powerful,  individual,  somewhat  coarse,  fibrous  mem- 
brane. The  powerful  obturator  fascia  inferior  is 
cleaved,  split,  for  the  transmission  of  the  pubic  ves- 
sels and  nerve.  The  canal  formed  by  the  separation 
is  known  as  Alcock's  canal.  The  several  membranous 
planes  of  some  of  the  fascia  in  the  pelvis  endow  it 
with  much  more  utility.  One  plane  may  tear  without 
the  other.  Several  cleavage  planes  are  characteristic 
of  fascia  in  other  localties  and  are  more  capable  of 
resisting  trauma  than  a  single  plane. 

The  coccygeal  muscle  arises  from  the  spine  of  the 
ischium  and  lesser  sacrosciatic  ligament,  becoming 
inserted  into  the  side  of  the  coccyx  and  two  lower 
sacral  vertebrse.     It  is  a  flat  musculo-tendinous  tri- 


28  THE  VAGINA  AND  PERINEUM; 

angular  plane,  aiding  to  close  the  posterior  pelvic  out- 
let. Its  anterior  border  is  in  contact  with  the  poste- 
rior border  of  the  levator  ani  muscle,  of  which  it  is 
practically  a  continuation  backward  and  covered  by 
the  same  fascia,  viz.,  the  levator  ani  fascia  superior. 
The  posterior  border  bounds  the  anterior  margin  of 
the  great  sacrosciatic  foramen.  The  lesser  sacro- 
sciatic  ligament,  which  is  formed  by  a  degeneration 
of  the  superficial  muscular  fibers  of  the  coccygeus, 
takes  the  place  of  the  continuation  of  the  levator  ani 
fascia  inferior.  The  coccygeus  muscle  is  fading  out 
of  existence,  belonging  originally  to  a  large  tailed 
animal.  The  origin  and  insertion  of  the  coccygeus 
muscle  and  lesser  sacrosciatic  ligament  are  identical. 
They  are  so  strong  that  practically  they  never  yield 
so  as  to  be  involved  in  colpoperineorrhaphy.  How- 
ever, the  coccygeus  muscle  is  described  in  order  to 
show  that  its  fascia  should  be  named  the  coccygeal 
fascia,  which  can  not  admit  of  confusion.  The  infe- 
rior surface  of  the  coccygeus  muscle  is  doubly 
strengthened,  not  only  by  the  lesser  sacrosciatic  lig- 
ament, but  by  the  superior  surface  of  the  great  sciatic 
ligament  which  represents  the  proximal  tendon  of  the 
long  head  of  the  bicep  femoris.  The  tendon  of  the 
long  head  of  the  biceps  formed  an  attachment  at  the 
tuberosity  of  the  ischium.  The  coccygeus  fascia 
covers  the  coccygeus  muscle  and  has  an  area  of  about 
3J  square  inches  on  each  side  of  the  median  line  of 
the  pelvis.  The  pyriformis  muscle  arises  fsom  the 
lateral  portions  of  the  second,  third  and  fourth  pieces 
of  the  sacrum,  from  the  inferior  border  of  the  great 
sacrosciatic  notch  and  from  the  great  sacrosciatic 
ligament.  It  passes  out  of  the  pelvis  through  the 
great  sacrosciatic  foramen,  becoming  inserted  into 
the  upper  border  of  the  great  trochanter.  It  is  the 
most  posterior  muscle  which  aids  in  closing  the  pelvic 
outlet.     It  serves  as  a  bed  on  which  the  sacral  nerves 


HOW   TO   MEND   THEM.  29 

may  rest.      It  is  covered  by  the  pyrifonnis  fascia, 
which  is  a  continuation  of  the  obturator  fascia  above 
and  the  coccygeus  fascia  anteriorly.     After  leaving 
the  obturator  and  coccygeus  fascia  it  rapidly  thins 
out  into  a  transparent  thin  membrane.     It  is  perfo- 
rated by  the  internal  iliac  vessels  which  leave  the 
pelvis  by  the  great  sciatic  foramen.     The  pyriformis 
fascia  is  attached  to  the  surface  of  the  sacrum  inter^ 
nal  to  the  origin  of  the  pyriformis  muscle  from  the 
posterior  border  of  the  coccygeus  muscle  to  the  ileo- 
pectineal  line  which  passes  along  the  border  of  the 
wing  of  the  sacrum  to  the  sacro-iliac  joint  and  finally 
it  is  attached  to  the  superior  margin  of  the  great 
sacrosciatic  foramen  from  the  ischial  spine  to  the 
sacro-iliao  point.     The  pyriformis  fascia   covers   an 
area  of  about  five  square  inches  on  each  side  of  the 
pelvis.     The  sacrum  is  lined  by  a  thin  fibrous  mem- 
brane which  we  will  name  the  sacral  fascia;  hence, 
the  internal  pelvis  is  lined  by  the  obturator  fascia 
superior,  the  levator  ani  fascia  superior,  the  coccygeal 
fascia,  the  pyriformis  fascia,  and  the  sacral  fascia. 
This  nomenclature  we  recommend  as  simple,  and  as 
facilitating  the  easy  acquisition  of  the  internal  fascige 
of  the  pelvis. 

The  use  of  the  levator  ani  fascia  superior  is :  a,  to 
sustain  the  pelvic  viscera,  and  is  analagous  to  the  fas- 
cia tranversalis-abdominalis;  b,  to  form  a  pouch  on 
each  side  for  the  pelvic  viscera,  which  assists  in  clos- 
ing the  pelvic  outlet  above  the  muscular  floor;  c,  to  fix 
the  pelvic  viscera;  d,  with  its  superior  pad  of  fat  and 
snow-white  connective  tissue,  to  support  the  pelvic 
peritoneum;  e,  to  resist  the  pressure  of  the  abdominal 
muscles  and  the  diaphragm,  and/,  to  serve  the  useful 
purpose  of  separating  the  perineal  tissue  from  the 
peritoneum. 

This  latter  anatomic  condition  limits  inflammatory 
and  infective  processes  from  either  perineal  or  peri- 


30 


THE  VAGINA  AND  PERINEUM; 


toneal  spaces.  Further,  the  levator  ani  fascia  superior 
forms  the  pelvic  floor,  and  by  its  strength  prevents 
pelvic  hernia.  The  blood-vessels  are  placed  sijperior 
and  the  nerves  inferior.     The  levator  ani  fascia  su- 


Fig.  9.— (Author.)  An  illustration  to  demonstrate  that  in  deep  lacer- 
ations of  the  pelvic  floor  the  levator  ani  fascia  superior  and  inferior  is 
torn  with  its  intervening  muscle,  the  levator  ani.  The  rent  or  tear  is 
shown  by  R,  R,  and  R,  R,  on  the  right  side.  The  needle  armed  with  the 
thread  (X)  will  pass  through  the  muscle  and  its  two  layers  of  fascia  in 
order  to  restore  the  integrity  of  the  pelvic  floor.  XL,  iliac  fascia ;  Up,  the 
beginning  of  the  obturator  fascia  superior  at  the  ischiopectineal  line; 
OS,  the  obturator  fascia  superior ;  W,  the  white  line ;  O,  the  obturator 
fascia  inferior  divided  by  the  white  line;  I.  O,  the  obturator  internus 
muscle;  F,  the  fat  in  the  ischiorectal  fascia;  A,  the  levator  ani  fascia 
superior;  B,  the  obturator  fascia  inferior;  V,  the  vagina;  S,  intrapelvic 
space ;  Y,  the  cervix ;  P,  deep  transverse  perineal  muscle,  and  2,  the  super- 
ficial; B,  the  sphincter  ani  externus;  M,  deep  layer  of  triangular  liga- 
ment; S,  superficial;  N,  deep  layer  of  superficial  perineal  fascia. 


HOW  TO   MEND   THEM.  31 

perior  and  inferior  limits  nearly  all  fistulse  in  and 
to  one-half  inch  above  the  anus.  A  disadvantage  of 
the  levator  ani  fascia  superior  is  that  it  is  perforated 
by  nerves  and  vessels  which  carry  sheaths  of  con- 
nective tissue ;  these  sheaths  allow  infective  proc- 
esses to  pass  from  the  perineal  tissue  to  the  subperito- 
neal tissue  and  vice  versa.  Deficiencies  occur  in  the 
fascia,  excavations  which  are  filled  with  fat.  The 
fascia  of  the  pyriform  muscles  consists  of  an  exten- 
sion backward  of  the  obturator  superior  and  levator 
ani  fascia  superior.  Both  fascial  planes  blend,  the 
one  from  the  anterior  margin  of  the  sacrosciatic  fora- 
men and  the  other  from  the  posterior  margin  of  the 
cocygeus  into  a  thin  membrane  which  covers  the 
pyriformis  muscle  and  the  sacral  plexus  of  nerves. 
The  pyriformis  fascia  is  perforated  by  the  gluteal  ves- 
sels and  nerves  to  gain  the  gluteal  region.  This  plane 
of  fascia  is  so  thin  and  delicate  that  one  can  scarcely 
dissect  it  without  tearing  it.  The  levator  ani  fascia  in- 
ferior (anal  or  ischiorectal  fascia)  lies  in  immediate 
and  intimate  contact  with  the  inferior  surface  of  the 
levator  ani  muscle.  This  fascia  begins  at  the  white 
line  and  becomes  lost  on  the  rectal  wall.  It  is  very 
intimately  connected  with  the  muscles.  The  levator 
ani  fascia  superior  and  inferior  blend  with  the  rectal 
wallabout  one-half  to  three-fourths  inch  above  the  anus, 
and  rectal  perforations  generally  occur  below  the  in- 
sertions of  the  above  fascia.  The  fibers  of  this  fascia 
are  included  in  all  deep  suturing  of  extensive  colpo- 
perineorrhaphy.  By  including  its  fibers  in  the 
sutures,  the  relations  of  the  levator  ani  may  be  par- 
tially restored  to  the  normal  relations.  The  sacral 
and  coccygeal  fascia  lines  the  anterior  surface  of  the 
sacrum;  it  has  localized  thickenings  and  thinnings 
The  thickest  portions  are  those  located  along  the  lat- 
eral margins  of  the  sacram  and  especially  around  the 
anterior  sacral  foramina.     The  triangular  ligament 


32  THE   VAGINA   AND   PERINEUM; 

(deep  perineal  fascia)  closes  in  the  pelvic  floor  in 
front.  It  is  the  result  of  the  union  of  the  obturator 
fascia  extending  from  both  sides  toward  the  center. 
It  is  a  prolongation  of  the  obturator  fascia  across  the 
pubis,  and  Winslow  called  it  the  ligamentum  inter- 
ossei  pubis;  Carcassone,  the  ligamentum  perineale; 
Colles,  the  ligamentum  triangulare  urethrse.  It  is 
the  deep  blade  of  the  fascia  perinei  and  is  an  integral 
part  of  the  obturator  fascia.  It  is  the  middle  fascia 
of  the  perineum,  or  Camper's  ligament.  It  fills  up 
the  deficiency  found  between  the  anterior  or  pubic 
insertions  of  the  levator  ani  muscle.  It  is  a  wonder- 
fully powerful  structure  in  fixing  the  lower  end  of  the 
vagina.  It  is  stronger  in  males  than  in  females.  It 
is  the  structure  which  retains,  with  powerful  grip, 
the  anterior  end  of  the  vagina  forward  and  upward. 
The  vagina  pierces  the  triangular  ligament  whose 
fibers  fix  themselves  in  and  around  the  vaginal  walls. 
It  joins  posteriorly  with  the  lower  margin  of  the  in- 
ferior edge  of  the  superficial  perineal  fascia.  If  one 
dissects  away  all  structure  from  the  vagina  except 
the  triangular  ligament  it  will  become  apparent  at 
once  what  a  powerful  support  it  is  to  the  lower  end 
of  the  vagina.  The  triangular  ligament,  as  its  name 
implies,  is  triangular  in  shape,  aponeurotic  in  struc- 
ture, extending  as  a  tense  septum  between  the  anterior 
part  of  the  perineum  and  pelvis.  It  is  attached  on 
either  side  to  the  rami  pubis  and  ischium.  Its  infe- 
rior or  posterior  inferior  margin  is  ill-defined,  blends 
with  the  superficial  perineal  fascia  at  the  ischioperi- 
neal  fascia,  where  it  gradually  loses  itself  on  the 
lower  surface  of  the  levator  ani  muscle.  It  sustains 
and  fixes  the  urethral  can^.  It  is  pierced  by  the 
vagina  at  its  base  or  weakest  portion.  It  serves  the 
useful  purpose  of  connecting  the  bladder  and  vagina 
to  the  pubis,  and  of  retaining  adjacent  organs  in 
fixed  relations.     By  its  connection  with  the  ischio- 


HOW  TO   MEND   THEM.  33 

perineal  ligament  (fascia)  and  levator  ani  muscle  it 
serves  to  strengthen  the  inferior  region  of  the  pelvis 
posteriorly,  and  aids  to  fortify  the  rectum  with  its 
muscles.  By  dissection,  it  is  plain  to  see  how  the 
triangular  ligament  closes  the  anterior  perineal  tri- 
angle, and  the  levator  ani  closes  the  posterior  perineal 
triangle.  The  triangular  ligament  extends  posteriorly 
on  each  side  of  the  vagina  and  blends,  not  only  with 
ihe  lower  ledge  of  the  superficial  perineal  fascia,  but 
very  intimately  interweaves  and  blends  with  the 
ischioperineal  ligaments,  making  a  powerful  fixation 
for  the  vagina  at  its  lower  end.  The  triangular  liga- 
ment in  conjunction  with  the  ischioperineal  liga- 
ments lends  to  the  perineal  body  a  "Punctum  Mobile." 
In  perineorrhaphy  much  attention  should  be  given  to 
the  factor  of  including  considerable  parts  of  the  tri- 
angular ligament  and  the  ischioperineal  ligaments  in 
the  deep  suture,  which  secures  a  forward  curve  to  the 
vagina,  and  also,  by  forcing  medially  adjacent  tissues, 
it  aids  in  producing  the  normal  curve  of  the  rectum 
backward.  This  ligament  is  a  very  important  struc- 
ture, serving  many  purposes  of  support,  and  aiding 
in  repair.  It  is  continuous  with  the  levator  ani  fas- 
cia inferior,  and  above  it  is  the  levator  ani  fascia  supe- 
rior. The  superficial  layer  of  the  deep  perineal 
fascia  of  Colles  is  a  strong  fibrous  membrane.  It 
extends  from  one  ischiopubio  ramus  to  the  other. 
This  membrane  blends  posteriorly  with  the  lower 
margin  of  the  triangular  ligament,  producing  partly 
ischioperineal  ligaments.  The  superficial  layer  of  the 
deep  perineal  ligament  is  less  in  extent  in  femalea 
than  in  men,  on  account  of  being  pierced  by  the 
vagina.  In  perineorrhaphy  it  is  of  considerable  aid 
in  restoring  the  relation  of  the  parts  by  allowing  the 
deep  sutures  to  draw  the  fascia  median  ward.  The 
ischioperineal  ligaments  extend  from  the  ischial 
tuberosities  to  the  perineal  body.     They  are  strong 


34  THE   VAGINA   AND   PERINEUM; 

aponeurotic  bands  of  a  very  resisting  character. 
They  result  from  the  union  of  the  lower  border  of 
the  triangular  ligament  with  the  deep  layer  of  the 
superficial  fascia.  The  fibers  of  these  ligaments  play 
an  important  role  in  extensive  colpoperineorrhaphy. 
These  ligaments  form  a  conspicuous  structure  in  every 
dissection  of  the  female  perineum.  In  the  advancing 
head  the  ischioperineal  ligaments  are  put  on  the 
stretch  and  gradually  forced  backward.  Should  they 
rupture,  by  extensive  flap-splitting  and  deep  suturing 
the  two  layers  of  fascia  which  blend  to  make  the  lig- 
ament could  be  partially  restored. 

Having  examined  the  structure  of  the  pelvis  in 
detail  we  may  now  combine  the  anatomic  factors 
which  explain  successful  colpoperineorrhaphy.  The 
first  is  the  restoration  of  damaged  fascia.  A  second 
important  factor  is  deep  suturing.  A  third  element 
in  a  successful  operation  is  the  restoration  of  function 
by  means  of  restored  muscular  relations.  A  fourth  is 
the  forcing  in  the  median  line  of  adjacent  perineal 
tissue,  and  a  fifth  factor  is  the  flap  method  of  opera- 
tion whereby  there  is  no  denudation  or  loss  of  tissue, 
and  the  flaps  (skin  and  mucosa)  avoid  infection  and 
insure  primary  healing.  The  flap  method  enables 
the  operator  to  reach  the  seat  of  the  lesion,  either  by 
splitting  tissue  or  deep  suturing  with  a  handled 
needle  with  an  eye  in  the  end.  Silk- worm  gut  which 
is  used  in  suturing,  being  non-septic,  may  remain  for 
weeks  in  position,  like  a  splint,  before  removing. 
Among  the  fasciae  of  importance  are:  The  levator  ani 
superior  and  inferior,  the  triangular  ligament  and 
deep  layer  of  the  superficial  fascia,  and  the  ischio- 
perineal ligament.  The  operation  of  colpoperineor- 
rhaphy is  the  result  of  evolutionary  processes  of 
failures  and  successes.  In  the  beginning,  it  was  con- 
sidered sufficient  to  unite  the  superficial  or  external 
tissues  at  the  site  of  the  lesion.     This  experiment 


HOW    TO    MEND    THEM.  35 

soon  demonstrated  its  own  failure,  and  later  it  was 
deemed  essential  to  restore  the  deranged  and  lacer- 
ated muscular  elements  in  the  pelvic  floor.  The 
attempt  at  successful  colpoperineorrhaphy  by  reunit- 
ing external  tissue  at  the  site  of  the  lesion  or  restor- 
ing deranged  or  lacerated  muscles  to  normal  relations 
proved  a  failure  to  such  a  degree  that  it  was  evident 
that  some  other  factor  played  a  role;  this  factor  was 
the  fascia.  The  restoration  of  the  lacerated  tissue  at 
the  site  of  the  wound,  with  the  deranged  and  ruptured 
muscles,  and  the  restoration  of  the  deranged  fascia 
are  the  three  factors  on  which  successful  colpoperi- 
neorrhaphy rests.  To  Dr.  T.  A.  Emmet  must  be 
given  the  credit  of  the  view  that  the  pelvic  fascia 
played  an  important  role  in  successful  colpoperineor- 
rhaphy. Experimental  labors  on  the  perineum,  in  a 
desultory  manner,  have  been  carried  on  for  fifty 
years.  But  only  lately  have  experimental  and  ana- 
tomic data  been  judiciously  combined  so  as  to  render 
clear  what  are  the  useful  methods  in  colpoperineor- 
rhaphy. All  successful  surgical  procedures  demand 
an  anatomic  basis.  The  deranged  and  lacerated  parts 
in  colpoperineorrhaphy  must  be  restored  in  a  manner 
similar  to  that  in  operation  for  hernia.  The  success- 
ful surgical  procedures  in  colpoperineorrhaphy  have 
passed  through  the  same  evolutionary  process  as  have 
the  various  operations  for  hernia.  In  hernia  we  must 
restore  the  anatomic  relations,  the  obliquity  of  the 
inguinal  canal,  so  that  its  valve-like  action  makes  it 
impossible  for  the  viscera  to  again  protrude.  In  col- 
poperineorrhaphy, not  only  the  anatomic  parts  should 
be  restored,  but  the  various  canals  and  outlets  must 
also  be  restored,  to  ensure  permanent  success.  Deep 
suturing,  so  essential,  is  only  groping  after  an  ana- 
tomic base  to  restore  the  ground  work.  The  same 
ideas  are  involved  in  the  views  of  discerning  surgeons, 
who  suggest  that  if  the  sutures  include  sufficient  of 


36  THE   VAGINA   AND   PERINEUM; 

the  rectovaginal  septum,  or  if  they  are  introduced 
deep  enough  to  make  forward  traction,  or  if  they 
include  the  sulcus  on  either  side  of  the  bulging 
vaginal  wall,  the  operation  will  be  successful.  Dr. 
W.  R.  Wilson  wrote  a  short  but  comprehensive  arti- 
cle on  the  subject,  suggesting  excellent  principles, 
but  modestly  claiming  that  the  anatomic  basis  is  still 
imperfectly  understood.  In  the  subject  of  colpo- 
perineorrhaphy  the  origin  of  the  lesion  demanding 
operation  should  be  studied.  The  cause  of  the  lesion, 
requiring  repair,  is  almost  always  the  result  of  (the 
first)  labor,  more  rarely  other  forces"  produce  sacro- 
pubic  hernia.  The  lesions  of  the  perineum  may  come 
from  the  forward  movement  of  the  head  jlacerating 
the  levator  ani  fascia  superior  and  inferior,  with  dam- 
age to  the  ischioperineal  (ligament)  fascia  and  tearing 
of  the  triangular  ligament,  with  consequent  inevitable 
lesion  of  the  deep  perineal  fascia.  This  will  destroy 
the  tone  of  the  posterior  vaginal  wall,  because  the 
fascia  has  been  separated  from  the  vaginal  wall  near 
its  outlet.  If  the  distinct  ischioperineal  (ligament) 
fascia  be  torn,  which  is  quite  frequent  in  labor,  the 
vulvar  end  of  the  vagina  falls  backward  and  begins  its 
condition  of  rectocele;  its  fascial  (and  doubtless  mus- 
cular) supports  have  been  torn  away.  With  a  torn 
levator  ani  fascia  superior  the  pelvic  viscera  will  inev- 
itably descend,  for  it  is  unphysiologic  for  a  muscle  to 
act  as  a  continuous,  tensionized  support  for  viscera. 
But  it  must  be  remembered  that  the  fascial  layers  of 
the  pelvis  are  not  only  of  value  as  visceral  supports 
by  separate  and  distinct  connection  in  themselves, 
but  they  are  of  significant  importance  as  serving  a 
means  of  visceral  support  and  for  a  point  of  attach- 
ment for  muscles  lying  between  their  blades.  The 
levator  ani,  which  is  the  most  important  muscular 
apparatus  on  the  pelvic  floor,  serves  by  its  fascial 
attachments  as  a  visceral  support  to  the  rectal  and 


HOW   TO   MEND    THEM.  *      37 

vaginal  walls  as  well  as  to  the  pelvic  floor,  for  the 
uterus  is  supported  by  the  intact  pelvic  floor. 

The  pelvic  floor  may  be  considered  as  composed  of 
two  widely  overlapping  valves  ( Hart) .  Whatever  dis- 
turbs the  relations  of  these  valves  tends  toward  sacro- 
pubic  hernia.  The  anterior  pelvic  valve  is  composed  of 
the  bladder,  drethra,  anterior  vaginal  wall  and  retro- 
pubic fa ,  The  posterior  pelvic  valve  is  composed  of  the 
posterior  vaginal  wall,  perineum  and  rectal  wall.  The 
pubic  segment  is  attached  to  the  symphysis  pubis  and 
composed  of  loose  connective  tissue.  The  retropubic 
fat  is  loose  and  spongy,  the  peritoneum  may  be  easily 
stripped  away  from  the  bladder,  and  the  bladder  from 
the  vagina.  In  labor,  this  segment  becomes  elevated 
and  is  the  one  which  easily  becomes  deranged,  or 
acquires  pathologic  conditions  and  especially  is  liable 
to  prolapse  or  sacropubio  hernia.  The  levator  ani 
fascia  superior  becomes  torn  away  from  the  walls  of 
the  bladder  and  vagina,  allowing  the  intra-abdominal 
pressure  to  force  the  bladder  and  vagina  downward. 

When  the  uterus  prolapses  (sacro-pubic  hernia) 
the  anterior  vaginal  wall  appears  at  the  vulva  first. 
The  strong  levator  ani  fascia  has  been  torn  from  its 
walls  and  when  the  same  fascia  has  been  extensively 
torn  from  the  bladder  it  prolapses  also.  In  vesical 
prolapse  the  peritoneum  with  its  many  cleavable 
planes  of  subperitoneal  (fascia)  tissue  becomes  torn 
from  the  bladder.  The  sacral  valve  of  the  pelvic 
floor,  consisting  of  the  posterior  vaginal  wall,  the 
perineum  and  rectum,  is  attached  by  strong  fascial 
connections  interwoven  by  muscles  to  the  coccyx  and 
sacrum.  In  labor,  this  segment  is  forced  backward 
and  straightened  out.  If  it  becomes  defective  by 
laceration  at  the  perineal  body  the  vagina  loses  its 
normal  curve  and  sacro-pubic  hernia  is  initiated,  i.  e., 
retroversion  begins,  which  is  the  inevitable  factor  in 
sacropubic  hernia.     The  uterus  itself  has  nothing  to 


38  THE  VAGINA  AND  PERINEUM: 


do  with  prolapses.  Intra-abdominal  pressure  and 
defective  sacral  and  pubic  segments  account  for  pro- 
lapse; the  sacral  segment  is  fixed;  the  pubic  segment 
is  movable. 

The  functions  required  of  the  pelvic  floor  are  to 
resist  intra-abdominal  pressure  and  to  allow  rectal 
and  vesical  functions.  The  structural  anatomy  of 
the  pelvic  floor  must  not  only  be  studied  in  general 
as  to  it  segments,  valves,  muscles  and  fascia  but  each 
individual  organ  should  be  studied  as  regards  its  sup- 
ports. The  uterus  has  its  individual  supports,  which, 
though  not  separate  from  the  fascia  and  muscles, 
should  be  well  considered,  for  colpoperineorrhaphy 
may  be  required  for  (prolapse)  sacro-pubic  hernia 
without  visible  lacerations.  The  first  elemental  indi- 
vidual supports  of  the  uterus  are  the  uterorectal 
(sacral)  ligaments.  They  consist  of  two  folds  of 
peritoneum  embracing  muscular  and  connective  tis- 
sue extending  from  the  posterior  surface  of  the  cer- 
vix to  the  rectum  (perhaps  some  fibers  do  extend  to 
the  sacral  fascia).  These  ligaments  are  an  extension 
of  the  muscular  conneclive  tissue  fibers  of  the  upper 
end  of  the  vagina  backward.  As  Dr.  Frank  Foster 
notes,  the  vagina  and  uterorectal  ligaments  form  a 
balance  beam  on  which  the  uterus  rests.  Yet  it 
should  be  borne  in  mind  that  organs  do  not  rest  on 
bases,  but  .are  swung  on  supports  or  mesenteries. 
The  brain,  liver,  heart  and  uterus  are  all  suspended 
by  supports  and  do  not  rest  on  other  organs  or  bases. 
The  uterorectal  ligaments  are  powerful,  peritoneal, 
muscular  and  connective  bands  which  vigorously  sus- 
pend the  uterus  by  the  neck.  Careful  dissections  and 
vaginal  hysterectomy  will  demonstrate  that  the  uterus 
eould  not  descend  without  the  uterorectal  ligaments 
became  elongated. 

These  ligaments  are  a  part  of  the  musculo-fascial 
support  of  the  pelvic  viscera.     The  vaginal  tube  sup- 


HOW   TO   MEND   THEM.  39 

ports  the  uterus  by  being  well  embraced  by  the  leva- 
tor ani  fascia  superior  and  the  levator  ani  muscle, 
and  also  by  being  well  padded  and  surrounded  by 
fascial  planes  of  connective  tissue  fixed  in  its  walls 
and  adjacent  structures.  Fat  pads  and  acts  as  a  sup- 
port by  stiffening  folds. 

In  colpoperineorrhaphy,  it  is  well  to  remember  that 
we  have  a  fixed  pelvic  segment  and  a  movable  or  dis- 
placeable  segment.  It  will  aid  in  repair.  The  mov- 
able pelvic  segment  comprises  the  urethra,  bladder 
and  vaginal  walls,  This  segment  is  bound  together 
by  peritoneum  on  a  very  mobile  base  and  by  a  con- 
siderable mass  of  loose  connective  tissue. 

This  segment  becomes  displaced  by  labor,  distended 
bladder,  vagina  or  rectum.  If  its  fascial  connections 
become  torn,  sacropubic  hernia  is  inevitable.  The 
fascial  connections  are  considerable  above  the  vulva, 
consisting  of  the  levator  ani  fasciae  superior  and 
inferior  and  to  some  extent  of  the  levator  ani  muscle. 
Sacropubic  hernia,  arising  from  lacerated  fascia 
of  the  movable  pelvic  segment  is  recognized  by  the 
vagina  and  bladder  bulging  downward  at  the  vulva 
and  making  the  vulva  appear  as  a  waist  with  the 
puckering  string  gone.  The  worst  and  most  damag- 
ing cases  of  laceration  are  those  which  begin  from  the 
inside  and  progress  outward,  i.  e.,  the  fascia  begins 
to  tear  high  up  in  the  rectovaginal  septum,  on  the 
sides  of  the  bladder  and  vagina.  These  are  the  cases 
which  present  distressing  symptoms;  when  standing 
are  worse  on  account  of  disturbed  circulation  and  are 
pronounced  "prolapse"  by  the  general  physician.  In 
such  cases  the  anterior  vaginal  wall  appears  first  at 
the  vulva,  then  the  cervix  and  finally  the  posterior 
vaginal  wall.  The  bladder  gradually  sags  downward 
and  difiicult  urination  is  added  to  the  already  existing 
train  of  symptoms.  In  lacerations  of  the  sacral  seg- 
ment of  the  pelvis  the  lesions  are  more  visible.     The 


40  THE   VAGINA   AND   PERINEUM; 


perineal  body  suffers  especially.  It  straightens  out 
the  fixed  sacral  segment  and  retroversion  and  inevita- 
ble subsequent  sacropubic  hernia  results.  The  visible 
laceration  of  the  perineal  body  was  originally  consid- 
ered the  chief  requisite  for  repair  and  also  the  type  of 
colpoperineorrhaphy.  But  the  study  of  the  pelvic 
fascia  shows  why  the  operation  failed  or  succeeded. 
Frequently  it  may  be  observed  that  the  perineal  body 
is  visibly  torn,  but  no  evil  consequences  follow, 
because  the  fascia  remains  intact.  The  rectum 
belongs  to  the  fixed  segment.  It  does  not  prolapse, 
but  its  wall  stretches,  elongates.  As  the  advancing 
head  forces  forward  and  tears  the  levator  ani  fascia 
superior  and  inferior  as  well  as  the  ischioperineal  lig- 
aments, the  levator  ani  muscle  also  becomes  deranged 
but  practically  the  restoration  of  the  fascia  restores 
the  muscles.  The  muscular  layers  of  the  pelvic  floor 
are  two — superficial  and  deep  connected — and  blended 
at  the  perineal  body  both  by  the  muscular  and  fascial 
relations.  The  deeper  layer  is  the  levator  ani  mus- 
cle which  descends  from  the  sides  of  the  pelvis  in  the 
form  of  a  boat  or  bowl  to  its  attachments  on  the  pel- 
vic floor.  The  superficial  layer  consists  of  the  trans- 
verse muscles  of  the  perineum,  which  extend  fropa  the 
tuberosities  to  the  center  of  the  perineum  and  also 
the  bulbo-cavemosus,  which  surrounds  the  vaginal 
outlet.  All  the  muscles  are  related  to  fascia,  as 
the  levator  ani  inclosed  in  double  blades  of  fascia, 
i.  e.,  the  levator  ani  fascia  superior  and  inferior.  The 
deep  transverse  muscles  lie  between  the  triangular 
ligament  and  Colles  fascia.  The  bulbo-cavernosus 
and  superficial  transverse  muscle  lie  between  the  two 
superficial  perineal  fasciae.  The  ischioperineal  fascia 
is  but  the  thickening  of  the  lower  border  of  the  tri- 
angular ligament  and  Colles  fascia.  The  significant 
importance  of  the  fascia  of  the  pelvis  becomes  at  once 
apparent,  not  only  in  maintaining  the  integrity  of  the 


HOW   TO   MEND   THEM.  41 

pelvic  floor,  but  in  all  repair  of  the  same.  The  pelvic 
fascia  is  the  chief  element  in  maintaining  perineal 
muscular  relations.  The  pelvic  fascia  may  be  divided 
into  deep  and  superficial  layers,  according  to  the  deep 
and  superficial  layers  of  muscles.  The  deep  pelvic 
fascial  layers  are  united  to  the  more  superficial  pelvic 
fascial  layers  in  the  perineal  raphe,  holding  the  pelvic 
fascia  as  a  unit.  The  superficial  fascial  layers  of  the 
pelvis  are  attached  from  the  ischial  tuberosities  to  the 
pubic  rami  and  stretch  across  the  anterior  perineal 
triangle.  They  shut  off  the  pelvic  outlet  except  at  the 
vulvar  orifice.  Fascia  may  be  torn  without  its  asso- 
ciated muscle  being  torn.  In  perineal  laceration  the 
muscles  lying  between  the  fascial  layers  may  become 
separated  as  to  loops  or  as  to  the  attachments  of  one 
or  both  ends.  Also  the  fascia  of  the  levator  ani  muscle 
may  be  lacerated  in  different  localities  and  this  allows 
complete  repair. 

When  the  muscular  layer  between  the  fascial  layers 
separates,  the  muscular  fibers  retract  irregularly 
toward  the  proximal  end,  leaving  gaps  which  are  dif- 
ficult to  effectually  repair.  The  rupture  and  retrac- 
tion of  the  levator  ani  with  its  fascia  makes  the  deep 
sulcus  found  on  each  side  of  the  bulging  rectocele, 
because  the  fibers  of  the  levator  ani  retract  later- 
ally toward  the  pelvic  walls.  It  is  evident  there  is  a 
deeper  factor  in  perineal  lesions  than  visible  lacera- 
tions. The  deficiency  in  perineal  lesions  is  not  in 
proportion  to  the  apparent  extent  of  the  injury. 
Every  physician  has  noticed  multipara  with  consider- 
able external  laceration  of  the  perineum,  with  appa- 
rently little  discomfort,  and  with  the  pelvic  organs 
but  slightly  disturbed,  while  in  other  cases,  with 
slight  apparent  lesions,  complaints  are  serious.  I 
have  seen  extensive  visible  lacerations  with  almost 
no  complaints  and  apparent  health.  Again,  we  may 
observe  cases  when  the  perineum  does  not  appear 


42  THE   VAGINA   AND   PERINEUM 


lacerated,  but  the  prolapsed  vagina,  the  bulging  rec- 
tooele  and  vesicocele  appear  at  the  vulva  in  a  remark- 
ble  degree.  In  fact,  as  Dr.  Emmet  remarks,  it  looks 
like  a  bag  which  has  lost  its  puckering  string.  There 
is  a  different  explanation  for  each  of  the  above  classes. 
In  one,  the  pelvic  fascia  has  suffered  in  the  lesion, 
and  in  the  other,  only  a  few  muscle  loops  and  possi- 
bly the  perineal  body.  When  the  lesion  involves  the 
pelvic  fascia  its  consequent  result  is  that  the  circula- 
tion is  deranged  seriously,  because  the  vessels  are 
held  in  definite  relations  by  the  fascial  planes,  hence 
the  discomfort  on  standing  and  exercising  is  from 
congestion.  Baker  Brown  simply  united  the  torn 
tissue  at  the  vaginal  outlet.  Seldom  does  this  sim- 
ple measure  afford  any  real  relief  from  perineal  lacer- 
ation, for  subjects  with  such  visible  slight  traces  suf- 
fer but  little.  In  general  the  operations  for  the  relief 
of  perineal  laceration  are  a  failure.  If  the  rectovag- 
inal septum  (fascia  and  muscle)  be  not  brought  in 
the  grasp  of  the  deep  sutures  success  will  not  be  ob- 
tained even  though  the  vulva  be  closed.  The  secret 
of  Emmet's  success  lay  in  the  denuding  of  the  vagi- 
nal septum,  i.  e..  utilizing  the  tissue  posterior  to  the 
vaginal  wall.  In  fact,  if  the  levator  ani  fascia  supe- 
rior and  inferior  be  not  lacerated  the  subject  suffers 
but  little  from  the  lesion,  though  the  perineal  body 
be  torn  through  to  the  rectum.  The  levator  ani  fas- 
cia superior  forming  the  gutter  or  sulcus  on  each  side 
of  the  vagina  is  firmly  blended  with  the  vaginal  canal 
as  the  same  strong  fascia  in  the  male  surrounds  the 
prostate.  In  labor,  in  perineal  laceration  we  should 
not  merely  look  for  lesions  in  the  posterior  commis- 
sure of  the  vulva,  for  that  is  done  by  the  escaping  head 
and  shoulders,  and  is  visible,  but  we  should  look  for 
concealed  lesions  of  the  strong  fascia,  the  sulcus  on 
each  side  of  the  vagina.  The  most  serious  lesion  of 
labor  may  occur  without  visible  external  injury.  This 


HOW   TO   MEND   THEM.  43 

lesion  is  in  general  a  separation  of  the  fascia  from 
the  vaginal  wall.     If  the  fascia  be  torn  from  this,  the 
posterior  vaginal  wall  will  not  be  drawn  against  the 
anterior  and  the  canal  will  be  filled  within;  it  will  be 
like  an  open  collapsed  bag.     The  fascia  together  with 
the  muscles  holds  the  vaginal  and  rectal  canals  in  a 
closed  condition,  excluding  air.     The  ballooning  out 
of  the  vagina  with  but  little  injury  to  the  perineal 
body  is  indicative  of  fascial  lesions  within  the  pelvic 
cavity  along  the  vaginal  canal.     The  vaginal  recto- 
oele  is  due  to  the  drawing  aside  of  the  levator  ani 
fascia  superior  and  but  little  to  the  external  lacera- 
tion.    The  beginning  of  discomfort  on  assuming  ex- 
ercise is  due  to  deranged  pelvic  circulation,  to  dila- 
tion and  straightening  out  of  veins,  to  non-uniform 
support  of  the  blood-vessels  and  nerves  by  the  proper 
connective  tissue.     The  advancing  head  crowds  the 
fascia  forward,  and  if  the  labor  is  terminated  without 
forceps,  the  rents  begin  chiefly  in  the  rectovaginal 
septum.     It  is  well  to  decide  what  and  where  the  lac- 
eration is,  so  that  tissues  may  not  be  either  denuded 
or  split  unnecessarily,  for  it  is  not  unfrequent  to  see 
tissues  united  which  were  never  involved  in  the  lesion. 
Perhaps  sufficient  has  been  demonstrated,  anatomi- 
cally and  clinically,  to  show  that  the  lesions  of  the 
perineum  which  disable  and  discomfort  the  patient 
are  chiefly  lacerations  of  the  fascia  and  secondarily 
of  the  muscles.     On  this  view  we  base  our  labors. 
If  this  be  the  case,  we  can  easily  see  that  Emmet 
secured  success  by  denuding  an  elliptical  area  of  the 
vaginal  mucosa  on  each  side  in  the  vaginal  sulci. 
The  curve  of  the  denuded  area  corresponds  to  the 
posterior  curve  of  the   rectovaginal   septum,  and  is 
situated  within  the  introitus.     Now,  by  introducing 
deep  antero-posterior  satures,  the  levator  ani  fascia 
superior  and  inferior  may  be  reunited,  restoring  the 
curve  of  the  posterior  vaginal  wall  and  the  fascial 


44  THE   VAGINA  AND   PERINEUM*, 

layers  at  the  vulvar  outlet.     In  reuniting  the  levator 
ani  fascia  superior  and  inferior  the  levator  ani  muscle 
becomes  also  reunited,  but  in  an  imperfect  degree. 
The  levator  ani  is  closely  embraced  by  its  superior 
and  inferior  fascial  planes,  as  from  its  origin,  inser- 
tion and  relation  it  depends  on  its  closely  associated 
fascia.     The  restoration  of  the  function  of  the  levator 
ani  muscle  must  be  accomplished  through  restoration 
of  its  intimate  planes  of  fascia.     If  success  depended 
on  th«  muscle  chiefly,  it  would  be  necessary  in  recto- 
cele  to  reunite  the  separated  levator  ani  loops  anterior 
to  the  rectocele  in  the  median  line  or  raphe,  so  the 
symmetrical  muscular  action  would  be  restored.     It 
is  true  that  to  secure  muscular  action  of  the  levator 
the  loop  must  be  so  repaired  that  the  fibers  shall  start 
to  act  approximately  from  the  raphe  on  both  sides, 
but  this  is  accomplished  by  reuniting  the  levator  ani 
fascia  as  near  as  possible  in  the  median  line,  which 
brings  the  muscular  loops  with  it.     The  levator  ani 
fascia  superior  and  inferior  is  really  a  sheath  for  the 
levator  ani  muscle  to  accomplish  its  functions.     The 
sheath  can  not  be  torn  without  creating  damage  to 
the  muscle.     In  rectocele,  this  fascia  is  so  torn  and 
stretched  that  the  anterior  wall  of  the  rectum  loses 
its  muscular  support  and  bulges  forward.     Whether 
the  sutures  be  introduced  antero- posteriorly  or  trans- 
versely, it  matters  but  little,  if  they  include  in  their 
grasp  the  levator  ani  fascia  existing  in  the  lateral 
sulci  of  the  vagina,  and  whatever  is  done,  to  be  suc- 
cessful, the  rectovaginal  septum,  composed  chiefly  of 
fascia,  must  be  restored  to  reproduce  the  normal  curve 
of  the  posterior  wall  of   the  vagina.     Mr.  Lawson 
Taits'  flap  operation  on  the  perineum  accomplishes 
exactly  what  Emmet's  operation  in  the  lateral  vaginal 
sulci  does,  with  the  exception  of  denudation.     Both 
operations,  when  properly  and  successfully  executed, 
result  in  the  restoration  of  the  continuity  of  the  deep 


HOW   TO   MEND   THEM.  45 

and  superficial  fascial  layers  of  the  pelvic  floor,  with 
the  establishment  of  partial  or  complete  muscular 
function.  The  deep  sutures  reunite  the  structures 
(fascia  and  muscles)  at  or  near  their  normal  points  of 
attachment.  Anatomically  then,  the  objects  to  be 
obtained  in  an  operation  for  colpoperineorrhaphy  are 
1,  the  restoration  of  the  levator  ani  fascia,  superior 
and  inferior;  2,  the  reunion  of  the  fibers  of  the  leva- 
tor ani  muscle  so  that  it  will  functionate — both  fascia 
and  muscle  must  have  relations  at  the  perineal  attach- 
ment; 3,  the  restoration  of  the  transverse  perinei 
muscles  which  draw  the  vagina  lateralward,  causing 
it  to  remain  open :  4,  the  restoration  of  the  ischioperi- 
neal  ligaments  in  regard  to  the  perineal  body;  5,  the 
posterior  curve  of  the  vagina  must  be  reproduced  by 
restoring  the  rectovaginal  septum;  6,  a  new  perineal 
body  should  be  restored  so  that  the  natural  backward 
curve  of  the  rectum  and  forward  curve  of  the  vagina 
should  persist;  i.  e.,  normal  relations  should  be  estab- 
lished between  the  perineal  center  or  body,  on  the 
one  hand,  and  fascia  and  muscle  on  the  other.  The 
perineal  body — "  punctum  fixum  " — of  vulvar  surface 
relations  should  be  restored. 

The  pelvic  floor  is  composed  of  muscles,  fascise, 
areolar  and  elastic  tissue.  These  structures  are  inter- 
woven into  distinct  though  complicated  relations  and 
fill  the  gap  of  the  pelvic  outlet.  The  pelvic  floor  is 
composed  of  two  halves,  whose  structures  arise  from 
the  lateral  walls  and  join  in  the  medium  line.  There 
are  two  muscles,  two  fascise  and  two  ligaments  of  each 
kind.  If  one  will  carefully  study  in  dissection  the 
levator  ani  and  the  bulbo-cavernosus  muscle  he  will 
be  impressed  with  their  functional  comparison.  Both 
are  sphincter  muscles.  Both  have  connection  with 
skin  as  most  true  sphincter  muscles  possess.  The  three 
points  of  insertion  of  the  bulbo-cavernosus  may  be 
considered  as  one  muscle.     They  contract  together 


46  THE   VAGINA   AND   PERINEUM; 


and  have  a  similar  function.  The  common  feature  of 
the  two  muscles  is  their  attachment  to  the  terminal 
fibers  of  the  rectum  and  vagina.  The  sphincter  ani 
is  closely  united  to  the  muscles  of  the  pelvic  floor  by 
tendons  and  fascial  attachments.  The  object  of  the 
muscles  of  the  pelvic  floor  is  to  control  the  lower 
ends  of  the  vagina  and  rectum.  Fascial  structures 
are  common  to  muscles  which  have  to  afford  sustain- 
ing power,  as  those  of  the  abdomen,  back  and  thigh. 

GENERAL   VIEWS. 

As  we  employ  perineorrhaphy  to  repair  uterine 
prolapse  (sacropubic  hernia)  as  well  as  deficiency  of 
the  external  sphincter  apparatus,  the  subject  covers  a 
vast  field.  All  kinds  of  genital  supports — peritoneal, 
fascial  and  vaginal  sphincter  apparatus — must  be  con- 
sidered. To  have  prolapse,  both  peritoneal  and  fascial 
supports  must  yield,  as  well  as  the  occurrence  of  mus- 
cular relaxation.  No  one  support  to  the  exclusion  of 
all  others  can  be  claimed  for  the  uterus. 

The  utero-rectal  (sacral)  ligaments  which  consist 
of  peritoneal  duplicatures,  containing  fibro- muscular 
tissue,  are  very  efficient  uterine  supports.  The  peri- 
toneum itself,  on  account  of  its  intimate  connection 
to  the  pelvic  viscera  and  fascia,  doubtless  gives  con- 
siderable support. 

The  round  ligament,  with  its  peritoneal  duplicature 
the  broad  ligaments  holding  some  muscular  fibers 
and  the  vesico-uterine  ligaments  all  assist  in  support- 
ing the  genitals.  In  the  consideration  of  sacropubic 
hernia,  the  intra-abdominal  pressure,  the  state  of  the 
abdominal  walls,  as  well  as  the  visceral  supports, 
should  be  weighed.  Whether  the  patient  has  enter- 
optosis  is  a  very  significant  question.  The  peritoneal 
duplicatures,  with  their  contents,  constituting  mesen- 
teries of  the  genitals,  elongate  in  enteroptosis  just  as* 
they  do  with   the  stomach,  kidneys,  intestines  and 


HOW   TO   MEND    THEM. 


47 


other  viscera.  It  is  not  uncommon  to  find  a  uterus 
excessively  mobile,  due  to  relaxed  supports.  Dis- 
placements of  the  genitals  not  only  involve  their 
special  supports  and  the  pelvic  floor,  but  the  whole 
peritoneum  and  the  abdominal  walls. 

It  need  not  be  doubted  that  the  mechanism  of  the 
pelvic  viscera  is  complicated.  The  levator  ani,  closely 
ensheathed  in  its  superior  and  inferior  fascia,  forms 
a  diaphragm  through  which  the  viscera  find  an  outlet. 
By  introducing  the  finger  three-fourths  of  an  inch 


Fig.  10.— (Eobinson-Scholer.)    A  medium  degree  of  relaxed  vaginal 
outlet,  to  be  remedied  by  colpoperineorrhaphy. 

into  the  vagina,  the  ledge  made  by  the  fascia  and 
muscle  enclosing  the  vagina  can  be  distinctly  felt. 
The  muscle  normally  ensheathed  in  its  scabbard, 
drives  the  vagina  and  rectum  directly  forward  and 
upward  toward  the  pubic  arch.  The  fascia  inserts 
itself  into  and  embraces  the  lower  third  of  the 
vagina  and  is  the  important  support.  The  levator 
ani. (fascial  and  muscular)  supports  lend  to  the  lower 
third  of  the  vagina  a  firm  fixation,  quite  immovable, 


48  THE   VAGINA  AND   PERINEUM; 

forcing  its  walls  closely  in  contact  for  about  an  inch, 
producing  a  pronounced  vaginal  sphincter  apparatus. 
In  marked  contrast  to  the  lower  third  of  the  vagina 
is  the  upper  portion,  which  is  lax,  mobile  and  yield- 
ing, being  surrounded  by  loose  connective  tissue  only. 
The  urethral  portion  of  the  vagina  and  the  neck  of 
the  bladder  are  firmly  fixed  by  the  vesicopubic  liga- 
ments which  dwindle  off  into  the  white  line.  This 
can  be  seen  during  respiration  with  highly  relaxed 
and  displaced  genitals;  the  urethro- vaginal  portion 
remains  still,  while  the  remainder  of  the  organs  move 
to  and  fro  with  each  breath  or  diaphragmatic  move- 
ment. Superiorly  the  lower  vagina  is  extremely 
firmly  fixed  by  the  three  layers  of  firm,  fibrous  fascia 
— the  posterior  layer  of  the  triangular  ligament,  the 
anterior  layer  of  the  triangular  ligament,  and  the 
deep  layer  of  the  superficial  fascia.  These  three 
powerful  and  dense  fibrous  layers  originate  at  the 
margins  of  the  isohiopubic  rami  and  stretch  across 
the  arch  of  the  pubis,  surrounding  the  vagina  and 
being  intimately  blended  in  the  vaginal  walls.  To 
be  convinced  of  the  fact  that  these  fibrous  laminae 
are  the  all-important  supporting  structures  that  not 
only  retain  the  lower  end  of  the  vagina  in  position 
but  prevent  it  from  being  torn  away  at  labor,  one 
needs  only  to  dissect  away  all  supports  from  the  lower 
vagina  except  them,  and  then  by  tugging  and  drag- 
ging on  the  inlet  of  the  vagina,  note  their  almost 
unyielding  qualities.  Parts  of  these  fibrous  layers 
(triangular  ligament)  are  frequently  lacerated  in 
labor,  and  must  be  included  in  the  flap-splitting  and 
deep  sutures  to  restore  the  lower  vaginal  tube. 

Laterally,  the  vagina  is  firmly  fixed  against  the 
descending  rami  of  the  pubes,  not  only  by  the  so- 
called  triangular  ligament,  but  by  the  levator  ani  fas- 
cia superior  and  inferior  enclosing  the  levator  -ani 
muscle.     By  introducing  the  finger  for  about  an  inch 


HOW   TO   MEND   THEM. 


49 


into  the  vagina  and  palpating  the  i^osterior  and  lateral 
parts,  one  can  feel  a  blunt  band  running  from  the 
pubic  ramus  on  each  side  downward  and  uniting  be- 
hind the  vagina  in  a  still  thicker  and  more  blunt 
band.  This  is  the  free  edge  of  the  levator  ani  and  its 
double  fascia,  where  they  come  in  contact  and  em- 
brace the  vagina.  The  vaginal  canal,  below  the  free 
edge  of  the  levator  ani  and  its  fascise,  is  directed  for- 
ward by  the  perineal  body  and  triangular  ligament 
vrhile  the  same  body  directs  the  rectal  canal  back- 
ward. 


Fig.  11. — Robinson-Scholer.)  A  high  degree  of  relaxed  vaginal  outlet, 
to  be  remedied  by  colpoperineorrhaphy. 

The  lower  third  end  of  the  vagina  is  quite  thick, 
very  vascular,  possesses  turgidity  and  is  surrounded 
by  some  circular  fibers.  In  short,  the  lower  third  of 
the  vagina  possesses  a  distinct,  vigorous  sphincter 
apparatus  which  plays  an  important  r6le  in  the  sup- 
port of  the  sexual  organs  and  in  perineorrhaphy. 

In  making  a  division  of  the  supports  of  the  pelvic 
viscera  into  those  of  the  peritoneum  and  those  of  the 
sphincter  apparatus,  we  may  first  make  a  few  remarks 
on  the  deficiency  of  the  peritoneal  supports.     The 


50  THE  VAGINA  AND  PERINEUM; 

utero-rectal  (sacral)  ligaments  (extending  from  the 
rectum  to  the  neck  of  the  uterus)  are  the  most  import- 
ant of  the  peritoneal  supports.  If  they  relax,  the  cer- 
vix will  pass  downward  and  forward,  while  the  body 
and  fundus  of  the  uterus  will  pass  backward.  In  other 
words,  elongation  of  the  sacrorectal  ligapaents  is  the 
initial  stage  of  retroversion  and  descensus.  Retro- 
version changes  the  intra-abdominal  pressure  from 
the  posterior  surface  of  the  uterus  to  the  anterior  and 
superior.  After  retroversion  the  intra-abdominal 
pressure  is  exercised  on  the  top  and  anterior  surface 
of  the  uterus,  driving  the  pointed  neck,  like  a  conical 
wedge  downward  at  every  breath.  The  cervix  acts  in 
retroversion  as  a  wedge  or  cone,  and  gradually  forces 
the  sphincter  apparatus  to  yield.  The  filling  bladder 
forces  the  fundus  backward  and  the  full  rectum  pushes 
the  cervix  forward,  all  perfecting  the  retroversion,  the 
beginning  stage  of  prolapse,  by  elongating  the  utero- 
rectal  ligaments. 

In  colpoperineorrhaphy,  we  must  not  only  repair 
the  deficient  sphincter  apparatus,  but  the  cone-shaped 
descending  cervix  must  be  amputated  and  its  blunt 
end  turned  downward,  so  that  it  should  point  and  rest 
against  the  sacro-ooccygeal  region  (bone  and  liga- 
ments) instead  of  attempting  to  dilate  the  levator  ani 
muscle  at  every  breath  by  the  change  of  intra-abdom- 
inal pressure.  When  the  cervix  once  gets  firmly  into 
the  vulva,  i.e.,  into  the  vaginal  sphincter  apparatus, 
the  descent  is  rapid  and  inevitable.  The  upper  two- 
thirds  of  the  vaginal  walls  being  loose,  easily  descend 
with  the  uterus.  In  descensus  uteri,  the  vagina  is 
inverted,  showing  in  all  probability  that  intra-abdom- 
inal pressure  had  displaced  the  uterus  first  in  the  proc- 
ess of  descent.  An  intact  sphincter  apparatus-  will 
long  retard  a  descending  uterus.  The  anterior  vagi- 
nal wall  appears  first  in  prolapse;  however  the  vesico- 
pubic ligaments  may  still  retain  the  bladder  in  posi- 


HOW   TO   MEND   THEM. 


51 


tion.  Posteriorly,  the  peritoneum  descends  with  the 
cervix  and  upper  portion  of  the  vagina.  In  other 
words,  the  upper  part  of  the  rectum  and  vagina  are 
separated,  while  the  lower  rectum  and  vagina  are 
closely  connected  by  a  musculo- fascial  septum,  with 
the  thin  edge  of  the  wedge  upward. 

Rare  forms  of  prolapse  may  occur  where  the  cervix 
is  elongated  or  where  the  peritoneum  is  loosened  and 
stretched.  Space  forbids  reference  to  many  other  con- 
ditions and  kinds  of  peritoneal  supports. 


Fig.  12.— (After  Hegar  and  Kaltentoach.)  Baker  Brown's  method, 
about  1850. 

GENERAL    VIEWS    IN    THE    DEFICIENCY    OF    THE 
SPHINCTER    APPARATUS. 

The  vagina  should  engage  more  of  our  attention, 
because  it  is  on  this  apparatus  that  the  operation  of 
colpoperineorrhaphy  is  applied.  The  primary  factor 
which  produces  deficiency  in  the  supports  of  the 
sphincter  apparatus  is  labor.  Other  factors  play  but 
a  secondary  role. 


52 


THE   VAGINA   AND   PERINEUM; 


The  pelvic  fascia  is  not  infrequently  lacerated  near 
the  ischiopubic  rami;  where  the  fascial  sheath  is  rup- 
tured the  contained  muscular  fibers  also  suffer  lacera- 
tion. The  results  are  cicatrices  and  loss  of  substance, 
which  may  be  felt  by  palpation.  The  anterior  vagi- 
nal wall  generally  escapes  laceration,  but  the  posterior 
vaginal  wall  is  often  damaged,  showing  various  sized 
and  formed  lesions.  Relaxation  is  prominent  and 
closure  incomplete.  Instead  of  the  curved  lower 
canal  with  the  perfect  sphincter  apparatus,  there  is  a 


Fig.  13.— Dr.  Goodell's  method  of  colpoperineorrhaphy. 

patulous,  relaxed,  open  mouth,  resembling  a  tobacco 
pouch  which  has  lost  its  puckering  string.  Some- 
times the  vaginal  mouth  is  closed  by  an  anterior  and 
posterior  vaginal  fold,  for  a  considerable  distance  up 
the  vagina.  The  causes  of  displacements  of  the  sex- 
ual organs  are  so  numerous — as  elongation  of  the 
uterO' rectal  ligaments,  elongation  of  the  cervix,  lacera- 
tion of  the  levator  ani  fasciae,  muscles  and  triangular 
ligament,  intra-abdominal  pressure,  enteroptosis — that 
all  possible  factors  must  be  considered  in  repair. 
Repair  must  consist  in  correcting  vicious  forces,  as  the 


HOW   TO   MEND   THEM.  53 

pointed  cervix  should  be  amputated  and  turned  back- 
ward, the  posterior  vaginal  curve  should  be  restored 
with  a  perineal  body  to  turn  the  rectal  end  back  and 
the  lacerated  levator  ani  fascia  should  be  reunited. 

An  analysis  should  be  made  of  the  factors  produc- 
ing displacements  and  lacerations  in  the  genital 
organs.  Deficiencies  of  peritoneal  support  should  be 
considered  distinctly  from  deficiencies  of  the  sphincter 
apparatus ;  however,  both  may  be  often  combined. 
Yet,  after  all,  our  chief  attention  will  be  directed  to 
deficiencies  of  the  sphincter  apparatus,  for  on  it  de- 
pends prolapse  and  lacerations,  chiefly  arising  in  it. 
Deficient  primary  peritoneal  supports  give  rise  to 
vaginal  inversion  as  rectocele,  vesicocele,  bladder  and 
rectal  disturbances,  and  the  vaginal  mouth  loses  its 
puckering  string  condition.  In  colpoperineorrhaphy, 
the  whole  of  the  tissue  of  the  pelvic  floor  should  be 
utilized  for  support  by  forcing  it  into  the  median 
line.  This  will  restore  the  tonicity  of  the  pelvic 
floor  and  form  a  firm  cicatrix  which  will  prevent 
sacro-pubic  hernia  and  also  reproduce  the  normal 
curves  of  the  canals.  To  accomplish  this,  extensive 
denudations  or  flaps  are  requisite. 

Successful  colpoperineorrhaphy  must  make  the  pel- 
vic floor  as  tense  as  possible  and  the  newly  formed 
cicatrix  will  aid  materially  in  its  success.  The  thick- 
ened tissue  (columns)  on  the  anterior  and  posterior 
vaginal  walls  are  remnants  of  Miller's  ducts,  which 
should  be  and  are  preserved  in  both  Dr.  Emmet's  and 
Mr.  Tait's  flap  operations.  They  furnish  evident  sup- 
port from  their  fibrous  masses.  It  may  be  observed 
that  nearly  all  successful  methods  of  perineorrhaphy 
make  the  denudations  in  the  vaginal  sulci  on  each 
side,  and  avoid  sacrificing  the  thickened  tissue  on  the 
anterior  and  posterior  vaginal  walls.  Reference  to  the 
labors  of  Bischoff,  Martin,  Hegar,  Kaltenback,  Schatz, 
Emmet  and  others  will  show  this  to  be  correct.    After 


54 


THE   VAGINA  AND   PERINEUM; 


performing  colporrhaphy  posterior,  Martin  makes  what 
may  be  called  an  extension  of  the  perineum  forward. 
This  is  an  excellent  method  of  restoring  the  anterior 
curve  of  the  lower  end  of  the  vagina.  Any  surgical 
procedure,  to  be  successful,  must  conform  to  the  ana- 
tomic structures.  The  denudation  of  the  lateral  vagi- 
nal sulci  or  the  flap  operations  conform  to  anatomic 
conditions,  and  so  far  have  proved  successful.     The 

a) 


^nus 


Fig.  14,  a  and  b.— Dr.  Kearny's  method  of  colpoperineorrhaphy. 

reason  denudation  in  perineorrhaphy  is  so  successful  is 
because  healing  in  the  vagina  occurs  with  consider- 
able certainty. 

THE   METHODS  OF  PERFORMING   PERINEORRHAPHY. 

The  methods  of  perineorrhaphy  may  be  classified 
into  three  divisions,  viz. :  Those  which  start  at  the 
vulva  (denudation)  ;  those  which  attack  the  lower 
vaginal  portions  (denudation);  those  which  depend 


HOW   TO   MEND   THEM.  55 

on  the  flap  procedure  (which  embraces  colpoperine- 
orrhaphy). 

Numerous  methods  of  perineorrhaphy  have  been 
tried  since  the  days  of  Ambrose  Par6,  Dieffenbach 
and  Baker  Brown,  when  they  simply  united  the  super- 
ficial tissue  which  was  situated  on  each  side  the  visi- 
ble  laceration.  This  was  a  superficial  vulvar  proced- 
ure and  was  of  small  value  except  to  prepare  the  way 
for  more  useful  methods. 

HISTORY. 

If  the  ancients  performed  successful  perineorrhaphy, 
I  am  unable  to  obtain  the  records.  Colpoperineor- 
rhaphy  as  a  modern  operation  can  scarcely  boast  of 
being  more  than  a  century  old.  Surgeons  sought  to 
prevent  prolapse  by  excision  of  the  vaginal  wall  so 
that  the  resulting  inflammation  would  produce  a  con- 
tracting cicatrix.  Others  applied  caustics  for  the 
same  reasons.  According  to  Schroeder,  Girardin- 
Laugier  employed  the  blue  stone.  Phillips  used 
"smoking  saltpetre;"  so  did  Laugier,  Velpeau,  Ken- 
nedy, Dieffenbach,  Colles  and  Simon.  Chippen- 
dale sought  to  stir  up  inflammation  and  cicatricial 
contraction  in  the  vagina  by  the  very  questionable 
method  of  infecting  it  with  gonorrheal  virus.  Opera- 
tors have  attacked  the  vulva  or  vagina.  The  vulva 
was  first  attacked  by  such  surgeons  as  Baker  Brown 
and  Pare.  Fricke  was  the  pioneer  who  performed 
episiorrhaphy  which  consisted  of  denudation  of  both 
labia  and  union  by  sutures.  The  failures  of  Fricke's 
episiorrhaphy  induced  later  surgeons  to  operate  higher 
up  in  the  vagina,  which  finally  resulted  in  the  Emmet 
and  Tait  methods.  Mende  suggested  denudation  in 
the  region  of  the  hymen.  Malgaigne  thought  it 
should  be  done  deeper  in  the  introitus.  Jobert  caut- 
erized the  vagina  when  it  protruded,  and  after  the 
exfoliation  of  the  eschar,  united  the  raw  surfaces  with 


56  THE   VAGINA   AND   PERINEUM; 


sutures.  Desgranges  employed  chlorid  of  zinc  to 
produce  cicatricial  contraction.  Marshall  Hall  was 
among  the  first  to  employ  elytrorrhaphy.  He  cut  out 
oval  or  long  segments  of  the  vaginal  mucosa  and 
united  the  denuded  surfaces  with  sutures.  Dieffen- 
bach  formed  flaps.  Velpeau  was  one  of  the  first  sur- 
geons to  do  successful  perineorrhaphy.  Langenbeck 
and  Karl  Braun  were  also  pioneers  in  the  operation. 
Early  operators  failed  on  account  of  lack  of  anatomic 
knowledge  and  prevailing  sepsis.  It  is  not  many 
decades  since  surgeons  learned  the  necessary  anatomy 
to  employ  in  colpoperineorrhaphy.  It  was  learned 
that  the  perineum  must  not  only  be  elongated,  but  a 
solid,  thick,  unyielding  pelvic  floor  must  be  con- 
structed that  the  sexual  organs  can  not  escape.  Per- 
haps Simon,  the  predecessor  of  Czerny  at  Heidel- 
berg, was  the  real  founder  of  colpoperineorrhaphy. 
when,  in  1867,  he  had  not  only  performed  but  added 
to  it  that  of  posterior  colporrhaphy .  Simon  freshened 
the  vaginal  wall  with  a  scalpel,  and  a  fenestrated 
speculum  was  placed  in  the  vagina  while  he  freshened 
the  upper  part  of  the  vaginal  wall  by  having  an  assis- 
tant introduce  the  finger  in  the  rectum  and  force  the 
vaginal  mucosa  out  at  the  vulva.  Veit,  Hegar  and 
Speigelberg  aided  to  develop  the  operation.  As  time 
passed,  instruments  for  support  were  gradually  dis- 
placed by  more  perfect  operations,  owing  to  more 
perfect  anatomic  and  pathologic  knowledge.  Most  of 
the  advances  are  due  chiefly  to  the  investigations  of 
Freund,  Huguier,  Martin,  Schroeder,  Wilms  (1879) 
and  Staude  (1880),  Breisky,  Huepfel  and  others  men- 
tioned in  this  monograph.  The  practical  execution 
of  colpoperineorrhaphy  by  the  celebrated  Heidelberg 
surgeon,  Simon,  is  the  real  foundation  of  subsequent 
labors.  The  success  attending  Simon's  addition  of 
colporrhaphy  demonstrated  that  some  form  of  vaginal 
operation  is  required  in  prolapse  or  deficiency  of  the 


HOW   TO   MEND   THEM.  57 

peritoneal  or  sphincter  apparatus  of  the  pelvic  floor. 
Celsus,  it  is  reported,  recognized  perineal  lacerations 
and  suggested  rest  in  bed  and  tying  the  legs  together, 
but  gave  no  surgical  views  of  repair.  Ambrose  Par^, 
a  fertile  genius,  demonstrated  t^e  use  of  sutures  be- 
fore 1880.  He  had  a  pupil  named  Guillenneau,  who 
restored  the  parts,  applied  the  sutures  and  secured 
curves.  Sancerotte  and  Noel  secured  success  about 
100  years  ago.  In  1829,  Dieffenbach,  surgeon  to  the 
Charity  Hospital  in  Berlin,  devised  useful  methods 
of  repair.  The  deductions  which  made  Dieffenbach 
celebrated  in  perineorrhaphy  were  his  methods  of 
lateral  incisions  (to  relieve  tension)  and  confining  the 
bowels*  by  the  aid  of  opium.  Chelius  opposed  this 
view,  insisting  that  the  bowels  should  be  loose.  In 
1852  Von  Langenbeck  gave  to  the  world  his  views 
through  a  memoir  written  by  Verhaeghe  of  Ostend. 
This  definitely  advocates  the  use  of  the  flap  and  split- 
ting of  the  rectovaginal  septum.  Marcy  gives  credit 
to  Dr.  Jenks  for  originating  the  flap.  Zweifel  gives 
Mr.  Lawson  Tait  credit  for  the  flap  splitting  method, 
to  which  he  is  no  doubt  entitled.  Hart  and  Barbour 
credit  A.  R.  Simpson  with  it.  Baker- Brown  published 
in  1854  his  first  edition  of  the  "  Diseases  of  Woman," 
in  which  he  advocated  Dieffenbach's  lateral  incisions, 
the  use  of  deep  quilled  sutures,  confining  the  bowels 
with  opium,  and  bilateral  division  of  the  sphincter. 
The  perineal  sutures  were  removed  the  third  day,  the 
remainder  later,  as  late  as  twelve  days.  All  sutures  were 
silk.  It  appears  that  Dieffenbach  and  Baker-Brown 
realized  that  the  denudation  should  be  carried  up  into 
the  posterior  vaginal  wall,  the  fact  which  Simon  ac- 
tually demonstrated.  It  is  reported  that  Mettauer  of 
Virginia  in  1830  used  lead  sutures;  other  metallic 
sutures  were  also  employed.  In  New  York,  in  the 
Woman's  Hospital,  Drs.  Sims,  Emmet  and  Thomas 
further  developed  colpoperineorrhaphy. 


58 


THE   VAGINA   AND   PERINEUM; 


At  present  the  operation  should  be  termed  oolpo- 
perineorrhaphy.  New  aids  have  also  been  developed 
in  regard  to  the  operation,  as  A.  Martin  taught  for 
years  that  one  should  begin  the  operation  for  colpo- 
perineorrhaphy  by  setting  up  an  involution  of  the 
uterus  by  amputating  the  cervix.  I  have  amputated 
the  pointed  conical  cervix  to  get  rid  of  the  dangerous 
dilating  wedge  to  the  sphincter  apparatus  of  the  pelvic 
floor,  to  prepare  for  successful  colpoperineorrhaphy. 


Fig.  15. — Colpoperineorrhaphy  according  to  Bischoff.  The  tongue- 
ehaped  portion  of  the  posterior  wall  of  the  vagina,  d,  is  not  dissected 
away.  The  denudation  in  this  operation  is  severe  and  bleeding  is  active, 
and  should  the  operation  fail  much  damage  is  done,  a,  a,  and  b,  b.  show 
the  method  of  introducing  the  sutures  and  the  shape  of  the  denuded  area. 

A  new  era  appeared  in  this  operation  when  the  flap 
began  to  be  formed.  So  far  as  records  are  accessible, 
the  late  Berlin  surgeon,  von  Langenbeck,  in  1852,  flrst 
described  the  flap  operation  in  perineorrhaphy.  He 
describes  the  splitting  of  the  rectovaginal  septum 
making  a  vaginal  flap  forward  and  a  rectal  flap  back- 
ward. Langenbeck's  description  of  perineorrhaphy, 
as  translated  by  Dr.  Marcy,  is  the  most  important 


HOW   TO   MEND   THEM.  59 

contribution  to  the  subject  before  the  time  of  Simon 
of  Heidelberg.  In  fact,  it  is  almost  equivalent  to 
Simon's,  and  in  one  sense  superior — in  the  use  of  the 
flap.  Perineorrhaphy  was  also  cultivated  by  Zary, 
Mureina,  Mensel,  Osiander,  and  Homer,  Perineor- 
rhaphy was  first  performed  with  silk  sutures,  the  hot 
iron,  and  chemicals.  About  three-quarters  of  a  cen- 
tury ago  metallic  (wire)  sutures  appeared.  In  1879, 
Werth  published  views  on  the  use  of  catgut  (animal 
ligatures)  for  buried  sutures.  Schroeder  chiefly  intro- 
duced the  buried  spiral  catgut  sutures  in  perineor- 
rhaphy. Silkworm  gut  is  one  of  the  best  materials 
for  sutures  in  general  use  at  present.  About  1872, 
Mr.  Lawson  Tait  began  the  use  of  a  certain  flap 
method,  consisting  of  resplitting  the  old  cicatrix  by 
the  use  of  scissors,  reuniting  the  produced  wound 
surfaces  by  means  of  sutures  which  do  not  penetrate 
skin  or  mucous  membrane.  The  utility  of  this  con- 
sists in  its  application  to  either,  or  both,  perineorrhaphy 
or  colpoperineorrhaphy.  The  flap  operation  was  dimly 
begun  by  Dieffenbach,  in  1829,  by  his  lateral  incisions 
to  relieve  tension.  The  flap  operation  was  definitely 
introduced  in  perineorrhaphy  by  von  Langenbeck, 
about  1850  ( "Memoire,"  1852,  by  Verhaeghe) .  In  1861, 
Colles  of  Dublin,  in  a  case  of  vesico- vaginal  fistula, 
resplit,  instead  of  paring  the  edges,  and  united  the 
resultant  flap.  In  1872,  John  Duncan  resplit  the 
edges  of  an  artificial  anus  and  reunited  them  with 
interrupted  catgut  sutures.  He  forced  the  flap  of 
mucosa  upward  and  drew  the  flap  composed  of  mus- 
culosa  and  serosa  outward,  thus  increasing  vastly  the 
denuded  surface  for  coaptation,  Hart  and  Barbour 
report  that  Dr.  A.  R.  Simpson  applied  this  flap  method 
to  perineorrhaphy.  Not  far  from  1872,  Mr.  Lawson 
Tait  applied  the  flap  operation  of  Langenbeck,  Colles 
and  Duncan  to  the  subject  of  perineorrhaphy.  He 
added  to  all  previous  labors  the  use  of  sharp-pointed 


60 


THE    VAGINA   AND   PERINEUM; 


elbow  scissors,  and  the  introduction  of  the  sutures 
without  penetrating  the  skin  or  mucosa  of  vagina  or 
rectum.  Silkworm  gut  sutures  are  employed  and  may 
remain  in  situ  for  ten  days  to  six  weeks.  According 
to  Sanger,  Stein,  a  Dane,  and  Voss,  a  Norwegian,  used 
similar  methods.  Later,  Hadra,  1887,  contributed 
valuable  views  on  the  restoration  ot.the  pelvic  floor, 
as  well  as  Marcy,  Jenks,  Byford,  and  Reamy. 


Fig.  16.— Dr.  Skene's  method.  The  area  D,  S,  is  denuded,  with  sutures 
in  situ  ready  for  tying.  The  method  resembles  that  of  Hegar  and  Staude. 

The  various  so-called  operations  for  (colpo)  perine- 
orrhaphy are  numerous.  The  first  operation  devised 
involved  the  vulva,  the  second  both  vulva  and  vagina. 

1.  Ambrose  Pare  (1580)  used  simply  sutures.  His 
pupil  Guillenneau  practised  and  improved  the  method 
(1649).  LaMotte,  Smellie,  Noel,  Murenna  and  Sance- 
rotte  practised  it. 


HOW   TO   MEND   THEM.  61 

2.  (1830)  Dieffenbach,  union  by  sutures,  and  ten- 
sion relieved  by  lateral  incisions.  Roux  (1834)  intro- 
duced it  into  France,  as  well  as  Mark  See  (1885),  and 
Polail]on(1885). 

3.  Baker  Brown  (1885,  union  by  sutures  of  the 
denuded  surfaces.  Wilms  and  Staude  cultivated  it 
in  Germany. 

4.  The  next  important  contribution  and  method 
devised  in  perineorrhaphy  was  von  Langenbeck's  flap 
method  (1850).  It  was  described  and  performed  with 
a  master  hand. .  Von  Langenbeck  also  suggests  that 
the  lateral  incisions  of  Dieffenbach  may  be  added,  ss 
it  obviates  dragging  from  movements.  He  advocated 
operation  immediately  after  the  injury,  if  possible.  Von 
Langenbeck  makes  several  distinct  steps  in  the  oper- 
ation :  vivification  of  the  free  border  of  the  recto- 
vaginal septum ;  the  undoubling  of  the  septum  and 
the  formation  of  the  flap  destined  to  form  in  the  new 
perineum,  the  anterior  side  of  the  triangular  space 
formed  by  two  canals,  vagina  and  rectum,  with  the 
perineum  as  the  base;  the  vivification  of  the  two  lips 
of  the  laceration;  the  insertion  of  the  sutures.  In 
this  operation  of  perineorrhaphy  von  Langenbeck 
started  the  flap  method.  The  flap  operation  protects 
the  wound  from  secretions  (vaginal  or  rectal). 

5.  In  1867  Simon  of  Heidelberg  began  the  real 
modern  steps  in  successful  perineorrhaphy,  which  was 
a  combination  of  perineorrhaphy  and  posterior  col- 
porrhaphy.  Simon  simply  improved  on  Baker- 
Brown's  method  by  not  only  freshening  the  perineum, 

.but  also  carrying  the  denudation  high  up  into  the 
vagina.  Simon  denuded  the  vagina  by  the  aid  of  a 
fenestrated  speculum.  The  upper  angle  of  the  vagi- 
nal wall  was  denuded  by  introducing  the  finger  into 
the  rectum.  Spiegelberg  and  Veit  aided  in  develop- 
ing the  subject.  Englehart  wrote  in  1871;  Banga  in 
1875  wrote  a  thesis  on  "  Kolpo-perineorplastik  "  ao- 


62 


THE   VAGINA   AND   PERINEUM: 


cording  to  Bisohoff.  In  1879  Hegar  and  Kaltenbach 
made  excellent  contributions.  In  1877  Le  Fort,  and 
Neugebaum  in  1881,  added  their  labors.  In  1877  Dr. 
Edward  W.  Jenks  of  Detroit  began  the  publication 
of  a  series  of  articles  on  perineorrhaphy  which  was 
really  a  flap  method  of  operating — a  distant  relative 


/?■ 


x\ 


Pig.  17.— Shapes  of  the  denuded  areas  in  colpoperineorrhaphy ;  a, 
Hegar;  b,  Simon ;  c,  Lossen ;  d,  Fitch.  In  a,  and  b,  the  dotted  line  repre- 
sent the  sutures  buried  by  tissue,  the  black  lines  the  exposed  sutures. 

of  von  Langenbeck's  procedure.  Dr.  Jenks  first  cut 
away  the  flap,  but  afterward  preserved  it.  The  method 
is  almost  precisely  similar  to  the  flap  method  attri- 
buted to  Dr.  A.  R.  Simpson  by  Hart  and  Barbour. 


HOW  TO  MEND  THEM.  63 

In  1879  Werth  began  to  use  buried  catgut  to  suture 
the  wound.  Dr.  Brose,  in  1883,  used  buried  animal 
ligatures.  H.  O.  Marcy  published  a  series  of  articles 
(1883)  on  perineorrhaphy,  advocating  the  flap  method 
and  buried  animal  ligatures,  which  he  first  used  in 
hernia  in  1881.  A.  Martin  of  Berlin  contributed 
excellent  labors  about  1882.  About  1880,  Pro- 
fessor Sohroeder  of  Berlin  obtained  excellent  results 
by  the  use  of  the  "6tage"  stitch,  a  continuous 
running  suture  of  catgut  buried  in  the  tissues  of 
the  denuded  surfaces.  As  a  pupil  of  Schroeder  and 
Martin,  I  observed  excellent  results  from  this  method. 
Bischoff  in  part  revives  the  flap  operation  of  Langen- 
beck.  However,  his  operation  was  quite  influential 
in  its  day.  Drs.  Byford,  father  and  son,  made  valu- 
able contributions  to  the  subject.  History  notes  that 
Simpson  carried  Duncan's  flap-splitting  to  the  peri, 
neum.  Simpson  performed  a  kind  of  four-flap  perine- 
orrhaphy for  many  years.  Perhaps  Mr.  Tait  imbibed 
some  of  his  views. 

In  1887  Dr.  Hadra  of  Texas  contributed  some  valu- 
able articles  on  the  subject  of  perineorrhaphy.  He 
suggested  vivification  of  the  posterior  vaginal  wall  for 
oolporrhaphy,  as  is  done  in  anterior  colporrhaphy. 
Since  1880,  the  laborers  in  the  field  are  legion.  Gradu- 
ally the  operation  of  perineorrhaphy  was  modified 
from  Pare,  Baker  Brown,  Dieffenbach,  Langenbeck 
and  Simon  to  Tait  and  Emmet.  The  modification 
consisted  in  denuding  not  only  the  perineal  tears,  but 
also  denuding  higher  up  in  the  posterior  vaginal  wall. 
Hildebrandt  especially  carried  the  denudation  well  up 
into  the  posterior  vaginal  wall. 

As  regards  suture  material,  Sims,  Thomas,  Emmet 
and  others  worked  out  the  application  of  metallic  wire 
to  plastic  labors  on  the  perineum  during  the  past 
thirty  years.  The  modem  tendency  is  to  use  silkworm 
gut  as  a  non-absorbable  suture.     This  may  be  left 


64  THE   VAGINA  AND   PEKINEUM 


weeks  in  a  wound,  and  acts  as  a  splint  in  coapting  the 
surfaces.  It  is  easy  to  remove.  To  Dr.  T.  A.  Emmet 
is  due  the  credit  of  introducing  a  method  of  perineor- 
rhaphy which,  until  recently,  was  the  one  generally 
practised  in  America.  In  1883  Dr.  Emmet  published 
a  new  method,  or  rather  a  modification  of  his  old 
operation.  Dr.  Emmet  denudes  the  sulci  on  each  side 
of  the  vagina  and  extends  the  perineum  forward.  His 
operation  is  intended  to  repair  perineal  fascia  and 
muscles.    Dr.  Emmet  holds  that  loss  of  support  fol- 


Fig.  ISA.— Emmet's  operation  (elytrorrhaphy  posterior)  for  prolapse : 
1  and  2  show  the  lines  of  union  of  denuded  surfaces  in  the  vaginal  sulci 
on  each  side  of  the  vaginal  column,  3,  which  still  remains. 

lowing  laceration  is  not  due  to  injury  of  the  perineal 
body.  The  loss  of  support  after  childbirth,  he  claims, 
is  due  to  rupture  of  perineal  muscles  and  fascia.  Dr. 
Emmet's  operation  is  difficult  to  make  clear  by  de- 
scription, but  it  consists  in  lateral  denudation  wholly 
within  the  vagina  to  s-uch  an  extent  that  when  the 
sutures  introduced  are  drawn  tight,  the  excess  or  slack 
in  the  posterior  vaginal  wall  disappears.  The  ostium 
vaginse  is  not  interfered  with  by  any  special  denuda- 
tion.    The  claim  of  his  operation  is  that  discomfort 


HOW  TO   MEND   THEM. 


65 


Fig.  18  B.— Staude  s  operation  (elytrorrhaphy  posterior)  for  prolapse ; 
1,  £.,  6,  4,  and  5, 6,  7,  8,  represent  the  denuded  vaginal  sulci ;  a,  5,  shows  the 
intact  column,  which  is  utilized  in  coaptation  and  fixation  of  the  denuded 
surfaces.  The  principle  of  saving  and  utilizing  the  column  is  the  same  as 
in  Martin's  and  Emmet's  operation. 


.KoS^*  18 C- Various  shapes  of  the  denudation  in  posterior  elytror- 
rhaphy,  represented  by  superimposed  diagrams:  1, 1  1  He^ar's-  2  2  2 
faXthlcolum^    ^^'*^'''  ^'^'^^^.'^  Winfkel's.    Observe  thtt  BischoS 


66 


THE  VAGINA   AND   PEEINEUM; 


disappears  immediately  after,  and  also  that  the  poste- 
rior vaginal  wall  is  brought  in  proper  position  and 
relation  to  the  anterior  wall,  as  it  is  in  the  normal 
condition.  The  view  maintained  in  this  surgical  pro- 
cedure is  that  the  perineal  body  is  insignificant  in 
support,  and  that  laceration  of  it  alone  impairs  but 
little  the  integrity  of  the  genital  supports.  But  the 
tearing  or  excessive  stretching  of  the  perineal  muscles 
and  fascia  at  their  attachments  to  the  genitals  quickly 
disturbs  the  delicate  balance  of  the  pelvic  organs. 

(a)  m 


Fig.  19  a  and  5.— Dr.  Jenks'  method  (flap)  of  perineorrhaphy.  The 
flap-splitting  is  executed  with  two  fingers  in  the  rectum,  and  a  scalpel. 
In  a  the  flap  is  marked  out  by  a  dotted  line ;  in  b  the  flap  is  completed, 
ready  for  suturing. 

There  is  one  point  against  Dr.  Emmet's  operation, 
and  that  is  the  relatively  blind  method  of  introducing 
the  higher  sutures.  In  other  words,  the  deep  layers 
of  the  lacerated  pelvic  fascia  may  not  be  included  in 
the  sutures  with  any  degree  of  certainty.  Dr.  Gill. 
Wylie  added  the  idea  that  Dr.  Emmet's  operation  would 
be  improved  by  denuding  the  posterior  vaginal  wall  a 
considerable  distance  and  then  continuing  the  denu- 


HOW   TO  MEND  THEM.  67 

dation  well  up  into  the  posterior  vaginal  sulci.  This 
method,  however,  sacrifices  a  larger  amount  of  poste- 
rior vaginal  wall. 

About  1872  Mr.  Lawson  Tait  of  Birmingham,  Eng- 
land, began  to  introduce  a  method  of  perineorrhaphy 
known  as  the  flap  method.  It  differed  from  all  others 
in  that  he  used  elbow  scissors  and  introduced  the  very 
deep  sutures  without  penetrating  the  skin  or  mucous 
membrane.  It  involved  no  loss  of  tissue.  The  direc- 
tion for  doing  the  Tait  operation  is  to  resplit  the  old 
cicatrix.  It  is  modified  according  to  the  condition  of 
the  case,  as  one  may  produce  anterior  and  posterior 
cuts.  Tait's  flap  perineorrhaphy  is  now  quite  gener- 
ally practised.  I  have  not  attempted  to  give  all  known 
historic  methods  of  perineorrhaphy,  but  simply  the 
chief  ones,  out  of  which  have  been  built  the  modem 
operation. 

GENERAL  INDICATIONS  FOE  PERINEORRHAPHY. 

1.  To  restore  rectal  and  vaginal  functions. 

2.  To  restore  pelvic  fasciae  and  muscles.  Normal 
fascia  is  required  for  normal  circulation. 

3.  To  restore  the  normal  relation  and  support  of 
the  posterior  wall  (colporrhaphy  posterior).  The 
posterior  vaginal  wall  sustains  the  anterior  vaginal 
wall  and  bladder. 

4.  To  provide  as  much  support  for  the  pelvio 
organs  as  the  restoration  of  the  perineal  body  will 
afford. 

5.  To  remove  the  neurasthenic  conditions;  to 
relieve  the  Innumerable  nervous  associations;  in 
short,  to  relieve  mental  and  physical  disturbances. 

6.  To  repair  and  check  sacropubic  hernia. 

7.  To  narrow  relaxed  pelvic  outlet. 

The  pelvio  floor  is  closed  from  behind  forward  by 
the  pyriformis  with  its  thin,  delicate  fascia,  the  firm 
sacrorectal  ligaments,  the  coccygeus  with  its  moder- 


68    '       THE  VAGINA  AND  PERINEUM; 

ately  strong  fascia,  the  levator  ani  muscle  with  its 
levator  ani  fascia  superior  and  inferior,  a  strong 
double  fibrous  protective  muscular  sheath,  and  also 
the  triangular  ligament,  a  powerful  layer  of  fibrous 
tissue.  The  coccygeus  with  its  fascia,  the  levator  ani 
with  its  double  fascia  and  the  triangular  ligament 
practically  constitute  the  pelvic  floor  and  seem  to 
separate  the  pelvic  cavity  from  the  perineum.  These 
are  essential  structures  in  oolpoperineorrhaphy.     The 


Fig.  20. — Method  of  denudation  of  vaginal  strips,  with  curved  scissors, 
from  one  side  of  the  vagina  to  the  other,  as  suggested  by  Dr.  Skene. 

levator  ani  fascia  (both  layers)*  pass  from  the  side  of 
the  pelvis  to  the  viscera,  firmly  attaching  themselves 
to  every  pelvic  organ,  forming  the  strong,  fibrous 
expansions  known  as  ligaments,  which  serve  to  hold 
the  pelvic  viscera  in  definite  fixed  relations.  In  peri- 
neorrhaphy, success  depends  on  the  restoration  of 
these  vital  supports;  a  significant  anatomic  fact  in 
pelvic  pathology  is  that  the  blo*od- vessels  lie  superior 
to  the  pelvic  fascia  and  the  nerves  inferior  to  it.     The 


HOW   TO   MEND   THEM.  69 

blood-vessels  which  arrive  in  the  i perineal  region 
pierce  the  pelvic  fascia  and  pass  chiefly  out  of  the 
great  sacrosciatic  notch. 

I'^he  levator  ani  fascia,  superior  and  inferior,  is  an 
important  structure  to  limit  infection.  It  separates 
the  ischiorectal  fossa  from  the  pelvio  cavity  proper 
where  so  much  loose  tissue  exists.  The  levator  ani 
fascia  is  pierced  by  vessels  and  nerves,  and  these  ves- 
sels and  nerves  are  surrounded  by  lymphatic  sheaths 
which  are  a  source  or  path  by  which  the  infection 
may  travel  from  the  pelvis  to  the  ischiorectal  fossa, 
and  vice  versa.  In  perineorrhaphy  the  levator  ani 
fascia,  superior  and  inferior,  is  incised.  The  opera- 
tion which  is  performed  for  the  restoration  of  the 
perineum  exists  under  different  names.  It  may  be 
termed  perineorrhaphy,  perineo-vaginal  restoration, 
perineal  extension,  perineauxesis,  or  the  flap  method. 
However,  I  think  the  best  name  is  colpoperineorrha- 
phy,  Colpoperineorrhaphy  is  an  operation  to  restore 
the  integrity  of  the  supports  of  the  sexual  organs. 
These  supports  include  those  of  the  peritoneum  and 
vaginal  sphincter  apparatus. 

The  perineal  body  is  situated  between  the  lower 
end  of  the  vagina  and  the  rectum.  Difference  of 
opinion  still  prevails  as  to  the  utility  of  the  perineal 
body  in  the  economy  of  the  female  genitals,  but,  from 
many  dissections  and  considerable  work  on  the  sub- 
ject, I  claim  the  following  functions  for  the  perineal 
body : 

1.  It  sustains  the  lower  ends  of  the  anterior  rectal 
wall  and  posterior  vaginal  wall. 

2.  It  supports  and  directs  the  discharging  end  of 
the  vagina  forward,  aided  by  the  triangular  ligaments 
and  levator  ani. 

3.  It  supports  and  directs  the  discharging  end  of 
the  rectum  backward;  the  rectum  is  directed  back- 
ward by  the  levator  ani  muscle. 


70 


THE   VAGINA  AND  PERINEUM; 


4.  It  not  only  keeps  the  discharging  ends  of  the 
rectum  and  vagina  widely  apart,  but  it  gives  both  a 
support  in  a  curved  direction  at  their  termination, 
thus  affording  mechanical  advantages  for  maintaining 
closure  of  both  apertures  and  preventing  the  easy  escape 
of  the  contents  of  either  canal.  The  wide  divergence 
of  the  two  canals  avoids  mingling  of  the  secretions 
and  consequent  irritation  from  decomposition.  The 
backward  hook  of  the  rectum  and  the  forward  hook 
of  the  vagina  are  an  important  factor  in  support,  and 


Fig.  21.— (After  Pozzi.)  LeFort's  (1889)  method,  which  is  similar  to 
Demarquay's  (1864-1875)  and  Eichert's.  An  incision  is  made  in  the  vagina 
at  the  point  C,  in  the  median  line  down  to  the  rectum ;  then  an  incision  is 
made  along  the  line  C,  D,  E:  another  line,  C,  G,  is  carried  along  the  rectal 
wall,  but  not  into  the  rectal  mucosa ;  another  line  joins  it  by  means  of 
E,  I,  G;  this  makes  a  distinct  triangle,  H  (seen  in  No.  3) ;  the  cicatricial 
tissue  is  removed  from  the  triangle,  H,  and  also  the  portion  of  the  vaginal 
wall,  marked  D,  is  seized  and  dissected  from  the  rectal ;  the  space  denuded 
is  D  and  H  (No.  3) ;  the  sutures  are  introduced  as  shown  in  Nos.  2  and  3. 
The  disposition  of  the  sutures  is  noted  in  No.  4.  The  operation  is  a  par- 
tial flap  method,  but  too  complicated  for  ordinary  practice. 


HOW  TO   MEND  THEM.  71 

prevents  gaping.  The  perineum  is  the  skin  between 
anus  and  vagina.  The  perineal  body  consists  of  skin, 
fat,  muscles,  fascia,  elastic  and  connective  tissue.  The 
perineal  body  as  a  support  in  itself  for  the  genital 
organs  has  been  much  overestimated. 

5.  It  serves  as  the  point  of  union  of  four  muscles : 
the  levator  ani,  the  sphincter  ani,  the  bulbo-caverno- 
sus,  and  the  transversus  perinei.  ^  It  serves  also  as  a 
point  of  union  of  the  various  fasciae. 

6.  It  acts  as  a  partial  support  of  the  pelvio  floor. 

7.  It  strengthens  a  tried  point  in  labor. 

8.  Laceration  of  the  perineum  to  any  considerable 
extent  destroys  the  nice  balance  between  anatomic 
structure  and  physiologic  function  in  the    female 

genitals. 

The  object  of  perineorrhaphy  is:  To  restore  partial 
ruptures;  to  restore  rectal  functions  after  complete 
ruptures;  to  prevent  prolapse  of  the  pubio  segment 
of  the  pelvic  floor. 

The  methods  of  performing  perineorrhaphy  are 
denudation  with  fixed  coaptation,  and  the  flap  method. 
The  etiologio  factors  of  lacerations  are  labor,  coitus 
and  trauma.  -Partial  laceration  of  the  perineum  may 
be  accompanied  by  vulvar  patency;  increased  vaginal 
secretion;  irritability  of  parts;  pathologic  condition 
of  nerve  structure;  neuralgic  or  neurotic  conditions 
induced  by  long-continued  local  lesions;  descent  (dis- 
tention) of  anterior  rectal  wall,  posterior  vaginal  wall, 
and  uterus.  Complete  laceration  of  the  perineum 
may  be  accompanied  by  vulvar  and  anal  patency; 
increased  vaginal  and  rectal  secretion;  incontinence  of 
bowel  contents  and  occasionally  of  bladder  contents; 
irritability  and  disease  of  the  surrounding  parts  from 
the  abnormal  secretions;  neuralgic  and  neurosal  con- 
ditions from  changes  in  nerve  structure;  melancholia 
(neurasthenia) ;  relaxation  of  the  displaceable  segment 
of  the  pelvic  floor  and  consequent  prolapse  or  hernia 


72  THE   VAGINA   AND   PEKINEUM; 

of  the  pubio  segment.  The  result  may  be  severe  con-- 
gestiou  from  a  disturbance  of  the  fascia  which  holds  the 
blood-vessels  in  relation.  If  the  blood-vessels  become 
distorted  in  their  bed,  disturbed  circulation  results.     | 

In  discussing  the  operation  for  colpopefineorrhaphy 
by  Emmet  and  Tait  I  shall  consider  these  both  founded  | 
on  anatomic  principles,  both  practical  and  successful 
operations,  and  both  arriving  at  the  same  end  by  dif- 
ferent methods.  However,  since  I  can  accomplish  by 
a  flap  method  exactly  what  Dr.  Emmet  accomplishes 
by  denudation  I  have  preferred  to  follow  the  flap  pro- 
cedure. I  have  employed  the  flap  method  for  over  six 
years,  comprising  over  one  hundred  operations  per- 
formed for  almost  all  kinds  of  perineal  laceration  and 
uterine  prolapse.  In  one  case  the  uterus  was  com- 
pletely prolapsed  for  fourteen  years.  Another  case 
of  thirty-four  years'  standing,  with  laceration  extending 
up  the  rectum  the  length  of  the  index  finger,  was  oper- 
ated successfully  after  three  previous  denuding  oper- 
ations. A  third  case  of  twenty-eight  years'  standing, 
was  lacerated  up  the  rectum  for  four  inches  and  had 
passed  through  three  unsuccessful  operations.  One  of 
twenty-seven  years'  standing,  with  three-inch  rectal 
laceration,  and  one  very  difficult  case  of  seven  years' 
standing,  with  several  unsuccessful  operations  by  well- 
known  gynecologists,  were  operated  on  with  perfect 
success.  In  these  cases  of  long  standing,  atrophy  was 
so  far  advanced  from  limited  blood-supply  andjnon-use 
that  it  required  extensive  flaps  in  order  to  secure  tissue 
for  a  perineal  body.  To  show  that  the  perineal  body 
is  not  significant  in  uterine  support,  several  of  those 
patients  continued  for  over  twenty-seven  years  with 
laceration  several  inches  up  the  rectum,  with  scarcely 
a  symptom  of  uterine  prolapse. 

It  will  be  observed  from  even  a  superficial  experi- 
ence that  the  patient  should  be  properly  prepared 
for   colpoperineorrhaphy.      If    the  patient    have    a 


HOW   TO   MEND   THEM. 


73 


long,  pointed  cervix,  which  acts  like  a  conic  wedge 
being  driven  downward  at  every  breath  or  increase 
of  intra-abdominal  pressure,  it  will  constantly  dilate 
the  vaginal  sphincter  apparatus  and  should  be  ampu- 
tated.    The  amputation  may  produce  involution   of 


Fig.  22  a  and  b.—Dr.  Skene's  naethod  of  denudation'  and  suturine  the 
rectum.  I'^x^-s  fuo 


74  THE  VAGINA  AND   PERINEUM; 

the  uterus.  A  long,  pointed,  conical  cervix  gener- 
ally has  behind  it  a  retroverted  uterus  which  precedes 
prolapse. 

Again,  if  there  is  a  cystocele  the  patient  should  be 
prepared  by  an  anterior  colporrhaphy.  It  may  be  that 
amputation  of  the  cervix  and  anterior  colporrhaphy 
can  be  done  at  the  same  sitting  and  anesthesia  as  the 
flap-splitting  colpoperineorrhaphy.  We  frequently 
perform  colporrhaphy  and  colpoperineorrhaphy  at  the 
same  time.  To  require  cervical  amputation  is  rather 
rare,  but  if  there  be  a  retroverted  uterus  with  pointed 
cervix  it  should  be  amputated  and  turned  backward 
against  the  sacrum.  In  short  we  must  imitate  nature 
as  much  as  possible  to  secure  success.  All  hernia  is 
the  same;  it  is  due  to  the  destruction  of  normal  valves 
and  the  straightening  out  of  oblique  canals.  Hence 
in  sacropubio  hernia  the  normal  obliquity  of  the 
vaginal  canal  must  be  restored.  Colpoperineorrhaphy 
restores  the  posterior  vaginal  wall  and  anterior  col- 
porrhaphy restores  the  anterior  vaginal  wall.  This 
is  not  often  needed  if  the  colpoperineorraphy  be 
thoroughly  performed.  Prolapse  is  prevented  by  peri- 
neorrhaphy, elytrorrhaphy,  episiorrhaphy  (or  some 
abdominal  operation).  Prolapse  may  be  considered 
as  a  downward  displacement  of  the  pubic  segment  of 
the  pelvic  floor;  the  sacral  segment  of  the  pelvic  floor 
shares  in  it  by  a  yielding  of  some  of  its  parts.  There 
are  so  many  varied  opinions  as  to  the  etiology  of  pro- 
lapse that  one  can  safely  say  the  subject  is  not  fully 
settled.  In  my  opinion  much  credit  is  due  to  Drs. 
Hart  and  Barbour  for  their  excellent  investigations 
on  the  structural  anatomy  of  the  pelvic  floor.  After 
considerable  careful  dissection  I  feel  quite  sure  that 
many  previous  views  must  be  changed,  but  it  is  hope- 
ful when  the  closest  and  most  continued  students  of 
the  pelvic  floor  come  nearly  to  the  same  conclusion. 
The  subject  of  prolapse,  I  think,  should  be  studied  out 


HOW   TO   MEND   THEM. 


75 


anatomically  and  clinically.  The  field  of  investiga- 
tion is  still  large.  As  time  goes  on  the  uterus  itself 
will  get  less  attention  and  the  pelvic  floor  more.  The 
subject  of  relaxation  and  submucous  laceration  will 
be  more  studied.  Relaxation  of  the  whole  pelvic 
floor,  due  to  repeated  labors,  infectious  processes  and 
anatomic  lesions  will  be  found  to  be  a  large  factor  in 
prolapse.  Insufficiency  of  perineal  support  should 
not  be  lost  sight  of,  and  the  sphincter  apparatus  of 
the  pelvic  floor  will  be  more  studied.     From  dissec- 


Fig.  23  a  and  6.— Fritsch-Walzberg  method.  The  figure  is  according  to 
Pozzi.  The  laceration  extends  into  the  rectum.  S,  rectovaginal  septum; 
F,  rectovaginal  septum  lacerated;  P,  perineum.  In  b  the  rectovaginal 
septum  is  split. 

tion  one  would  at  once  conclude  that  the  levator  ani 
fascia  and  the  triangular  ligament  were  the  main  sup- 
ports in  the  pelvic  floor,  and  the  relations  of  other 
supports  must  be  considered.  Dissection  is  the  only 
intelligible  way  to  understand  the  subject.  For 
example,  dissection  of  quite  a  number  of  bodies  has 
thoroughly  explained,  in  my  mind,  the  conflicting 
views  of  anatomists  and  gynecologists  as  to  the  posi- 


76 


THE   VAGINA   AND   PERINEUM; 


tion  of  the  uterus.  As  a  gynecologist  I  have  exam- 
ined several  thousand  women,  and  I  am  sure  that  the 
uterus  leans  forward  in  the  normal  condition.  Re- 
peated examination  on  the  back  and  while  standing 
will  prove  that  slight  ante  version  is  the  normal  posi- 
tion of  the  uterus.  Now,  the  anatomist  has  often 
insisted  that  normally  the  position  of  the  uterus  is  in 
the  hollow  of  the  sacrum.  I  have  repeatedly  found 
in  the  dead  subject  that  the  uterus  is  in  the  hollow  of 


Pig.  24.— (After  Hegar  and  Kaltenbach.)  BischofE's  method  of  colpo- 
perineorrhaphy.  He  denudes  high  up  on  each  side  of  the  posterior  median 
vaginal  column,  B,  B,A,  A.  This  method  partially  foreshadowed  Emmet's 
operation.  Note  the  butterfly  wings,  1,  2,  3,  d,  d.  Bischoff  saved  the 
posterior  vaginal. 

the  sacrum,  precisely  as  the  anatomist  has  described. 
Both  gynecologist  and  anatomist  are  correct.  In  the 
living  woman  the  normal  position  of  the  uterus  is 
that  of  anteversion.  In  the  dead  woman  in  dorsal 
decubitis  the  uterus  generally  lies  in  the  hollow  of  the 
sacrum.  In  just  such  a  manner  arise  the  differences 
of  opinion  relative  to  prolapse,  which  can  only  be 


HOW  TO  MEND   THEM.  77 

cleared  up  by  careful  personal  anatomic  and  clinical 
investigation.  A  comparison  of  different  causes  will 
soon  let  in  the  light. 

Though  the  peritoneal  supports  of  the  uterus  be 
deficient  they  can  be  put  at  rest  and  finally  cured  by 
carefully  planned  operations  on  the  vaginal  sphincter 
apparatus.  All  primary  uterus  supports  are  attached 
to  the  neck  of  the  uterus  and  before  the  uterus  shows 
such  signs  of  hernia  the  supports  attached  to  the  neck 
must  be  definitely  elongated.  Doubtless  the  uterine 
supports  are  frequently  elongated  by  Infective  pro- 
cesses and  hence  a  rest  by  repairing  and  fortifying 
the  sphincter  vaginal  apparatus  will  result  in  restora- 
tion. Especially  is  this  true  in  certain  forms  of 
retroversion.  If  the  uterus  remains  in  its  normal 
position  (i.  e.,  perfectly  movable)  no  retroversion  and 
consequent  prolapse  will  arise.  In  chronic  infective 
processes  the  pelvic  organs  at  times  swell,  soften, 
become  edematous,  ending  in  a  form  of  hypertrophy 
from  static  congestion.  I  have  frequently  observed 
this  slow  repeated  process  in  the  clinics. 

ETIOLOGY  OF  PROLAPSE. 

1.  Insufficiency  of  sphincter  apparatus:  a,  levator 
ani  muscle;  h,  triangular  ligament  (anterior  posterior 
layers  and  fascia  of  Colles) ;  c,  levator  ani  fascia,  supe- 
rior and  inferior;  d,  perineum  (composed  of  levator  ani, 
bulbo-cavernosus,  transversusperinei  and  sphincter  ani 
ischio-perineal  ligaments) ;  e,  vaginal  walls;/,  urethro- 
vaginal septum;  g,  recto-vaginal  septum;  A,. muscular 
and  elastic  tissue  on  lower  third  of  vagina. 

2.  Insufficiency  of  peritoneal  supports:  a,  utero- 
sacral  ligaments;  6,  round  ligaments;  c,  broad  liga- 
ments; d,  vesico-uterine  ligaments;  e,  perineum;/, 
elongated  cervix. 

3.  Intra-abdominal  pressure  increased  or  applied  in 
abnormal  directions. 


78  THE  VAGINA  AND  PERINEUM; 

4.  Relaxation  of  anterior  segment  of  pelvio  floor: 
a,  repeated  labor;  6,  submucous,  concealed  facial  lacer- 
ations; c,  subinvolution  of  pelvio  floor  and  organs. 

5.  Weight  of  uterus,  which  affords  surface  for  intra- 
abdominal pressure. 

OPERATIONS  FOR  PROLAPSE. 

1.  Tait's  flap  operation  (and  extension)  of  perineum. 

2.  Perineo-episiorrhaphy. 

3.  Elytro-perineorrhaphy. 

4.  Elytrorrhaphy. 

5.  'Amputation  of  cervix. 

6.  Shortening  of  round  ligaments  (Alexander- 
Adams). 

7    Shortening  of  broad  ligaments. 

8.  Fixation  of  the  uterus  to  the  abdominal  "wall 
(hysteropexy). 

9.  Schucking's  operation. 

10.  Herrick's  operation. 

11.  Mackenroat's  operation. 

The  operations  for  prolapse  hav0*been  as  varied  as 
the  views  of  its  causes.  Operators  have  attacked  the 
uterus,  vagina,  vulva  and  uterine  ligaments  to  accom- 
plish their  purpose.  The  pioneer  idea  in  prolapse 
was  to  close  up  the  vulva  so  that  the  uterus  could  not 
escape.  Thus  we  have  the  early  episiorrhaphy  of 
Fricke  and  Kuchler.  But  surgeons  soon  saw  that 
simply  closing  up  the  vulva  was  like  attempting  to 
board  up  Mount  Vesuvius.  The  forces  at  work  were 
not  at  the  vulva  but  deep  in  the  interior.  Then  came 
the  operations  on  the  perineum  with  all  their  variety, 
from  Guillenneau's  successful  case  through  Dieffen- 
bach,  Langenbeck,  Simon  and  Sims,  to  the  modern  flap 
operation.  Finally  to  episiorrhaphy  and  perineor- 
rhaphy were  added  operations  on  the  wall  of  the 
vagina  (colporrhaphy  and  elytrorrhaphy).  Elytror- 
rhaphy has  been  quite  a  successful  addition  to  gyne- 


HOW   TO   MEND   THEM. 


79 


cology,  but  it  is  a  denudation  operation  and  hence 
destroys  valuable  tissue.  I  have  observed  that  the 
European  operators  attempt  to  save  anterior  and  pos- 
terior columns  of  the  vagina.  Men  see  in  the  column 
a  valuable  piece  of  supporting  tissue,  and  some  of 
them,  like  Martin,  try  to  save  it.  Dr.  Emmet  has 
worked  along  the  same  line,  and  his  operation  is  one 
of  the  most  useful  of  its  kind,  and  if  mastered  and 
done  thoroughly  is  successful.  In  it  he  has  combined 
the  best  principles  of  the  denudation  method.     It 


Fig.  25.— (A.  Martin.)    Colpoperineorrhaphy  posterior  accordina-  to 
Hegar;  a,  IS  the  newly-built  perineum.  ^ 

saves  the  columns  and  denudes  the  areas  of  least 
resistance.  His  idea  of  supporting  the  pelvic  floor'  is 
certainly  correct.  If  the  flap-splitting  method  could 
be  made  use  of  in  this  operation  it  would  be  a  marked 
step  in  advance.  The  vulvar  and  vaginal  operation 
of  denudation  should  be  superseded  by  theflap-exten- 
sion  method,  which  might  be  called  perineo-episior- 
rhaphy.  It  is  done  with  no  loss  of  tissue  and  can  be 
carried  right  up  to  the  urethra.  The  amount  of  flap 
and  consequent  barrier  of  tissue  built  up  at  the  vulva 


80 


THE   VAGINA  AND*  PERINEUM; 


will  depend  on  the  depth  of  the  scissors'  clip  and  the 
amount  of  exposed  tissue,  and  also  much  on  the  man- 
ner of  suturing  the  surfaces  to  be  coapted.  The  flap- 
extension  method  will  form  one  of  the  best  supports 
for  prolapse.  The  objections  against  the  Alexander- 
Adams  operation  are:     1.  Unsatisfactory  reports  and 


Fig.  26.— Colpoperineorrhaphy  after  A.  Martin,  He  styles  it  elytror- 
rhaphia  duplex  lateralis.  The  first  step  is  to  resect  or  denude  the  two 
vaginal  flaps;  the  left  side  is  freshened  and  sutured;  the  right  side  fresh- 
ened with  the  sutures,  but  not  tied,    a,  a,  the  denuded  vaginal  flaps. 

the  bias  in  selecting  cases  for  the  operation.  2.  In 
quite  a  number  of  bodies  the  round  ligaments  can 
not  be  found.  In  many  cases  which  I  investigated 
no  muscular  ligaments  could  be  discovered  until  one 
got  inside  the  internal  abdominal  ring.     3.  No  oper- 


HOW  TO   MEND   THEM.  81 

f%u^^}^^^  ^^  ^^^^^  ^^®®^  *^®  difficulty  will  occur 
4,  1  he  danger  of  opening  the  peritoneum  5  The 
round  ligaments  are  insufficient  for  a  main  uterine 
support.  6.  Hernia  may  follow  the  operation  7  In 
case  of  uterine  adhesions  the  ligaments  will  not 
raise  and  support  the  uterus.  Results  will  not  be 
permanent.  The  round  ligaments  will  gradually  yield 
to  uterine  weight,  especially  if  there  be  an  enlarged 
uterus,  as  is  often  the  case  in  prolapse. 

Some  of  the  above  objections  may  be  modified   The 
Alexander-Adams  operation  is  an  excellent  one  in 
selected  cases;  in  retroversion  without  adhesions  it 
will  frequently  be  of  great  utility.     But  it  is  here 
mentioned  as  an  accessory  operation  to  colpoperine- 
orrhaphy.      Shortening  the   broad   ligaments    is  of 
questionable  value.     Hysteropexy,  or  the  fixation  of 
a  movable  organ,  is  against  all  physiologic  principles, 
bchuckmg  s  operation  for  prolapse  is  not  yet  estab- 
lished, and  it  seems  the  bladder  would  be  in  great 
danger  ot  being  wounded  during  the  operation.    Her- 
riok  s  operation  of  attaching  the  cervix  to  the  pos- 
terior vaginal  wall  has  made  little  definite  progress 
we  have  not  yet  learned  how  to  utilize  the  sacro^ 
;uterine  ligaments  in  prolapse.     Such  operations  are 
but  accessories  to  colpoperineorrhaphy.     The  advan- 
tages of  the  flap  operation  are: 
1.  The  ease  and  simplicity  of  its  performance 
^.  it  wastes  no  tissue;  if  it  fails  the  patient  is  no 
T\rorse  off  than  before  the  operation,  whereas  the  fail- 
ure  ot  a  denudation  operation  leaves  serious  defects 
/t.  V®.i       °^^y  operation  that  restores  in  a  natural 
method  the  perineal  body.      The  linear  cicatrix  is 
split  and  sutured   in   the  opposite  direction.      Dr 
l^mmet  s  operation  unites  the  perineal  wound  artifi- 
<5ialiy  by  uniting  tissues  not  previously  connected 

4.  It  withstands  subsequent  labors;  several  of  our 
operations  have  withstood  perfectly  subsequent  labors 


82 


THE  VAGINA  AND  PERINEUM; 


Mr.  Tait  informed  me  of  the  same  fact  in  many  of 
his  operations. 

5.  The  sutures  are  not  passed  through  skin  or  mu- 
cous membrane,  and  therefore  are  not  so  liable  to  sup- 
purate or  produce  pain. 

6.  The  certainty  of  healing. 


Fig.  27.— Second  step  in  A.  Martin's  colpoperineorrhaphy.  He  calls  it 
perineauxesis ;  a  and  b  show  the  lines  of  the  vaginal  denudations  sutured 
(elytrorrhaphy).  The  diamond-shaped  space,  1,  2, 3,  is  the  perineorrhaphy 
following  the  colporrhaphy  posterior.    The  letters  indicate  the  sutures. 

7.  The  flap  operation  secures  in  the  easiest  and 
most  convenient  manner  the  widest  possible  surface 
for  coaptation  and  healing  of  the  fasciae  and  adjacent 
tissues  in  the  median  line  for  support. 


HOW   TO   MEND   THEM.  83 

8.  The  pain  after  the  operation,  in  my  experience, 
is  less  than  after  the  denudation  operation. 

9.  Tait's  flap  operation  can  be  practised  successfully 
where  the  repeated  denudation  operation  can  not  be  per- 
formed because  of  loss  of  tissue  and  excess  of  tension. 


Fig.  28.— Martin's  operation  with  a  continuous  catgrut  suture  (etagr- 
enaht).    It  is  a  continuous  buried  suture. 

10.  The  short  time  required  to  do  Tait's  flap  oper- 
ation minimizes  shock. 

11.  The  resulting  cicatrix  is  in  its  natural  location 
and  linear,  and  will  thus  cause  less  peripheral  nervous 
disturbance. 


84 


THE   VAGINA   AND   PERINEUM; 


12.  The  stitches  leave  no  cicatrices  and  therefore 
will  cause  no  irritation.  One  can  observe  the  most 
practical  and  best  observers  trying  to  save  the  column 
and  trying  to  perform  denudations  in  the  vaginal 
sulci.  The  superiority  of  Tait's  flap  operation  is  that 
it  saves  all  tissue  and  builds  a  natural  perineum  in  a 
natural  location,  and  thus  subserves  natural  forces 


Fig.  29.— Martin's  operation  with  buried  catgut,  The  upper  part 
(elytrorrhaphy)  posterior  colporrhaphy ;  the  lower  part  (perineauxesis) 
perineorrhaphy;  6,  the  upper  end  of  thread;  c,  lower  end  of  the  catgut. 

according  to  nature's  original  law,  and  anatomic  struc- 
tures are  not  much  violated  by  cicatrices  and  cicatricial 
contraction. 

A  fact  not  generally  appreciated  is  the  neurosis,  the 
neurasthenic  condition  produced  by  perineal  lacera- 


HOW   TO   MEND   THEM. 


85 


tions.  The  visible  wound  is  not  always  commensurate 
with  the  suflPering.  There  may  be  a  visible  wound, 
an  infection  atrium,  or  simply  an  over-stretching  of 
muscle  and  fascia,  which  stretches  and  traumatizes 
the  peripheral  nerves,  producing  nervous  irritation. 
The  fascial  planes  which  hold  the  blood-vessels  in  dis- 
tinct relation,  are  so  damaged  that  congestion  and  de- 
congestion  of  the  pelvis  frequently  arise.  Healthy 
veins  should  be  spiral  and  uniform  in  caliber.     The 


Fig.  30.— Profile  view  of  A.  Martin's  colpoperineorrhaphy  posterior. 
A,  B,  elytrorrhaphy ;  D,  E,  C,  perineauxesis. 

laceration  of  the  pelvic  fascia  allows  the  veins  to 
straighten  out  and  become  irregularly  dilated.  This 
straightening  out  and  dilatation  produces  not  only 
blood  and  lymph  congestion,  but  peripheral  nerve 
pressure.  The  frequent  pelvic  congestion  and  de- 
congestion  from  deficient  blood-vessels'  support,  pro- 
duce conditions  which  favor  the  development  of 
pathogenic  microbes  in  the  genital  mucosa.  The  gyn- 


86 


THE   VAGINA   AND   PERINEUM; 


ecologist  sees  many  patients  with  neurotic  phenomena 
which  can  only  be  attributed  to  perineal  lacerations 
and  defects. 

When  the  sutures  are  tied  the  newly  formed  per- 
ineum will  look  enormously  longer,  but  it  will  soon 
shrink  to  the  natural  condition.  After  some  experi- 
ence one  can  do  the  flap  operation  so  that  on  healing 
the  linear  cicatrix  will   resemble  the  old  raphe  so 

V 


Fig.  31.— Hildebrandt's  method  of  denudation  and  suturing.  The 
dotted  Knes  show  the  sutures  under  the  tissues.  The  denuded  area  is  that 
of  a  trefoil.  Hepner's  method  of  suture  is  that  of  a  figure  8.  Cleveland's 
method  is  simply  a  peculiar  method  of  suturing. 

closely  that  one  can  scarcely  tell  after  six  months  that 
an  operation  has  been  performed. 

For  cystocele  the  flap  operation  can  also  be  performed. 
The  flap  method  is  alike  applicable  to  partial  and 
complete  perineal  laceration.  The  operation  is  best 
idemonstrated  on  complete  lacerations. 


HOW   TO   MEND    THEM. 


87 


GENERAL    CONCLUSIONS. 

1.  To  cure  saoropubio  hernia  (uterine  prolapse), 
perform  amputation  of  the  (sharp)  cervix;  anterior 
oolporrhaphy;  Tait's  flap  perineorrhaphy. 

2.  The  amputation  of  the  cervix  is  for  the  purpose 
of  removing  the  sharp  cervical  point;  directing  the 
cervix  backward;  restoring  the  uterus  to  normal 
position. 


Pig.  32.— (After  Pozzi.)  i^autenbach's  method  in  incomplete  rupture 
of  tHe perineum.  1,  suture  of  the  superior  angle;  2,  submucous  suture  of 
the  vaginal  wall ;  3,-buried  sutures  deep  in  the  wound. 

3.  The  anterior  colporrhaphy  is  for  the  purpose  of 
narrowing  the  vagina;  elevating  the  bladder,  directing 
the  cervix  backward  and  the  fundus  forward. 

4.  The  Tait  flap  perineorrhaphy  is  for  the  purpose 
of  restoring  the  perineum;  restoring  the  obliquity  of 
the  genital  canal;  restoring  such  a  central  floor  as 


88 


THE   VAGINA   AND   PERINEUM; 


will    efficiently    support    the    rectum,   bladder,   and 
genitals. 

5.  If  the  cervix  be  not  pointed  and  retroversion 
does  not  exist  amputation  of  the  cervix  may  be  omit- 
ted in  the  above  procedure. 

6.  If  the  uterus  and  bladder  be  in  normal  position 
and  the  vagina  not  prolapsed,  anterior  colporrhaphy 
may  be  omitted. 

7.  The  permanent  success  of  Tait's  perineal  flap 
operation  consists  in  extensive  flaps  (by  means  of 
front  and  back  cuts)  and  the  drawing  into  the  median 


Fig.  33. — Lauen stein's  suture  in  complete  laceration.  1,  introduction 
of  sutures  which  coapt  the  vagina  and  rectal  mucosa ;  2,  introduction  of 
the  perineal  sutures  after  the  vaginal  and  rectal  have  been  fastened. 

line  of  large  masses  of  lateral  tissue  for  a  pelvic  floor. 
These  lateral  masses  are  drawn  in  and  secured  for 
weeks  by  deep  sutures  of  silkworm  gut.  These  deep 
sutures,  six  to  eight  in  number,  act  like  splints  for 
four  to  eight  weeks,  and  though  part  of  the  wound 
suppurates,  the  sutures  maintain  it  in  coaptation  while 
it  granulates  and  heals. 

8.  Our  operations  have  proved  definitely  that  the 
rectal  sphincters  may  be  practically  restored  to  normal, 
even  after  long  periods  of  rupture.  One  case  of  thirty- 
four  years'  standing,  with  two  previous  unsuccessful 


HOW   TO   MEND   THEM, 


89 


denuding  perineorrhaphies  and  a  complete  laceration 
of  three  inches  up  the  rectum  was  restored  to  perfect 
function. 

9.^  The  three  surgical  procedures  described  will 
obviate  hysterectomy  in  many  cases. 

10.  The  flattening  out  of  the  operation,  or  the  yield- 
ing of  the  union,  or  the  stretching  of  the  parts  allow- 
ing prolapse,  will  depend  especially  on  the  flaps  and 
the  amount  of  tissue  permanently  drawn  into  the 
middle  line. 


Figure  34  A. 

12.  We  especially  insist  that  better  results  are  ob- 
tained by  allowing  the  silkworm  gut  sutures  to  remain 
in  position  for  from  four  to  six  weeks.  Should  any 
suppurate  they  may  be  removed  at  any  time.  Wounds 
do  not  heal  very  firmly  under  three  weeks. 

13.  We  feel  decided  in  stating  from  our  own  experi- 
ence that  the  flap  operation  should  not  be  disturbed 
by  dressings.  The  patient  should  be  kept  quiet  for 
three  days,  and  then  a  vaginal  douche  may  be  given 


90  THE  VAGINA  AND  PERINEUM; 

daily.  After  the  first  half  day  the  wound  is  hermet- 
ically sealed  by  its  own  oozing.  The  limbs  should  be 
tied  together  at  the  knees.  The  bladder  will  generally 
require  the  use  of  the  catheter  for  two  to  four  days. 
Morphin  injections  of  1/1 6  of  a  grain  may  be  given 
to  quiet  the  pain  and  induce  rest. 

14.  The  dissection  of  the  rectum  from  the  vagina 


Figure  34  B. 

for  one  to  three  inches,  was  added  from  my  own  ex- 
perience, as  I  never  saw  Mr.  Tait  do  this.  This  addi- 
tional procedure  lengthens  the  operation  to  fifteen 
to  thirty  minutes;  Mr.  Tait  performs  his  operation  in 
five  to  ten  minutes. 

15.  The  result  of  the  foregoing  surgical  procedure 
has  been  gratifyingly  successful. 

16.  The  flap  operation  fits  any  and  every  case,  for 


HOW  TO   MEND   THEM. 


91 


it  resplits  the  old  cicatrix  and  restores  and  adds  what 
is  required. 

17.  In  no  single  case,  in  over  150  which  I  have 
observed,  was  the  flap  operation  not  applicable. 

18.  The  flap  method  makes  little  scar  tissue,  as  the 
operative  procedure  is  performed  in  connective  tissue 


Figure  34  C. 

while  cicatrices  form  in  skin  and  mucosa.  In  the  flap 
oolpoperineorrhaphy  the  posterior  vaginal  wall  is 
made  to  sustain  the  anterior. 

19.  In  the  flap  operation  the  vaginal  walls  are  made 
to  give  their  full  support  to  the  uterus — the  posterior 


92         THt  VAGINA  AND  PERINEUM; 

wall  sustains  the  anterior  vaginal  wall  and  bladder — 
and  also  to  support  and  direct  backward  the  rectal 
wall. 

The  flap  perineorrhaphy  has  been  chiefly  revised 
and  introduced  to  the  profession  by  Mr.  Lawson  Tait 
of  Birmingham,  England.  It  is  true  the  flap  peri- 
neal operation  was  performed  in  various  ways  by  oth- 
ers, as  Duncan,  Colles,  Jenks,  Marcy  and  Langen- 


Fig.  34  A,  B,  C,  D.— (After  Pozzi.)  Freund's  method.  Freund  insists 
that  we  should  make  the  denudation  exactly  as  the  perineum  appeared 
■when  originally  torn.  For  example,  the  cicatrix,  O,  O,  originally  appeared 
as  large  as  B,  B,  X,  in  A,  and  should  be  denuded  to  that  size ;  the  line  X,  Y, 
in  B  represents  the  rectal  suturing ;  the  line  of  sutures,  B,  A,  B,  in  C  shows 
the  vaginal  part  sewed  up;  X,  Y,  corresponds  to  the  rectum  suturing; 
A.  C,  Y,  D,  in  C,  the  denuded  perineal  area,  which  is  still  unsutured; 
D,  the  final  disposition  of  the  sutures  in  Freund's  method.  It  is  an  excel- 
lent one,  but  complicated,  and  is  wrought  with  much  sacrifice  of  tissue 
if  the  operation  fails. 

beck.  But  Mr.  Tait  gave  it  a  new  impetus,  and  also 
performed  it  with  new  phases.  He  performed  it  with 
elbow  scissors  and  introduced  sutures  which  neither 


HOW   TO   MEND   THEM.  93 

penetrated  skin  nor  mucous  membrane.  As  a  pupil 
of  Mr.  Tait,  for  six  months,  I  had  ample  opportunity 
to  observe  his  methods  of  operation.  The  principle 
of  operation  consists  in  resplitting  the  old  perineal 
cicatrix  without  loss  of  tissue,  with  fixed  coaptation 
of  the  flaps.  After  observing  Mr.  Tait's  methods  I 
naturally  practised  the  operation  as  performed  by 
him  and  his  assistants.  About  a  year  later  I  began 
to  modify  the  operation  by  dissecting  the  rectum  and 
vagina  from  each  other  for  a  variable  but  long  dis- 
tance (1  to  2J  inches)  above  the  vulva  or  anus.  This 
modification  enabled  me  to  apply  it  to  almost  all  forms 
of  prolapse,  relaxed  vaginal  wall  or  perineal  lacera- 
tion; in  short,  in  all  conditions  requiring  perineor- 
rhaphy and  colporrhaphy  posterior.  The  objections 
raised  against  the  flap  method  we  found,  after  over 
six  years'  trial,  were  not  well  founded.  One  objection 
is  that  Tait's  flap  perineorrhaphy  is  a  "  skin  opera- 
tion." If  performed  superficially  it  may  be  subject 
to  the  above  criticism.  However,  such  criticism  can 
only  be  applied  to  imperfect  execution.  The  opera- 
tor must  carefully  guard  against  closing  the  vulva  too 
far.  One  can  easily  make  an  excessive  perineum  by 
the  flap  method.  This  objection  is,  as  a  matter  of 
fact,  worthless.  Another  objection  is  that  the  flap 
method  in  no  way  narrows  the  vagina.  This  objec- 
tion will  not  hold,  as  the  vagina  can  be  narrowed  so  as 
to  embrace  tightly  a  single  index  finger.  In  fact,  we 
can  dissect  the  rectum  and  vagina  from  each  other 
for  three  inches,  up  to  the  peritoneum,  or  as  high  as 
desired,  and  narrow  the  lower  third  of  the  vagina  as 
much  as  the  operator  sees  fit.  The  upper  two- thirds 
of  the  vagina  does  not  require  narrowing.  Another 
objection  is  that  it  does  not  approximate  the  fibers  of 
the  levator  ani.  It  is  the  operation  par  excellence  to 
unite  the  deranged  or  torn  levator  ani  fibers,  because 
the  dissection  is  carried  beyond  the  levator  ani  fascia 


94 


THE   VAGINA   AND   PERINEUM; 


superior  and  inferior  through  the  levator  ani  muscle. 
In  fact,  it  enables  the  operator  to  secure  both  the 
levator  ani  fascia  superior  and  inferior,  which  em- 
braces the  levator  ani  muscle.  One  must  secure  the 
levator  ani  fascia  in  order  to  secure  the  levator  ani 


Fig.  35.— (After  Pozzi.)  A.  R.  Simpson's  method.  It  is  really  a  flap 
operation.  In  the  left  hand  cut,  a,  b  and  c  represent  the  lines  of  incision 
to  make  the  flaps ;  S,  vagina ;  1,1,  vaginal  flap ;  2,  2,  rectal  flap.  The  scissors 
are  first  entered  at  b,  and  the  point  emerges  at  n,  and  then  a  clip  is  made ; 
second,  the  scissors  are  entered  at  1,  and  pushed  between  the  vaginal  and 
rectal  walls  over  to  1,  and  a  clip  makes  the  rectal  and  vaginal  flap.  Dissect 
the  vaginal  flap  from  the  rectal  as  high  as  the  case  requires.  To  do  this, 
seize  the  vaginal  flap  with  several  small  forceps,  which  the  assistant  can 
gently  hold;  also  seize  the  rectal  flaps  with  several  small  forceps  and  allow 
them  to  hang,  as  their  weight  is  sufficient  to  put  the  flap  on  tension ;  with 
the  two  fingers  in  the  rectum  and  a  pair  of  blunt-pointed  scissors  the  dis- 
section of  the  flaps  is  conveniently  made.  The  sutures  are  introduced  as 
shown  in  the  cut.  Observe  that  in  this  operation  four  flaps  are  made  and 
that  the  rectal  and  vaginal  walls  are  sutured  separately;  also  note  that 
the  sutures  1,  2,  3,  are  entered  by  passing  through  the  skin.  The  suturing 
and  flap  making  is  absolutely  different  from  that  of  Mr.  Tait's  flap  method, 
in  which  only  one  flap  is  made  and  no  sutures  enter  the  skin  or  mucosa,^ 
and  all  cutures  are  in  denuded  tissue. 


HOW    TO    MEND    THEM.  95 

muscle,  which  is  guarded  and  embraced  by  a  definite 
fascial  sheath.  The  flap  operation  reunites  the  pos- 
terior vaginal  fascial  septum  without  denudation,  as 
Emmet's  operation  unites  it  with  denudation.  Both 
Emmet's  and  Tdit's  operations  are  based  anatomic- 
ally on  the  same  principle — one  denudes  however, 
and  the  other  does  not,  but  employs  a  flap  to  cover 
the  wound.  My  practice  is  to  dissect  the  rectum  and 
vagina  in  the  lateral  sulci.  In  the  American  Text- 
book of  Gynecology  the  writer  on  "Flap-splitting 
Perineorrhaphy''  makes  the  following  absurd  state- 
ments: "Its  field  of  usefulness  is  very  limited  indeed. 
Practically  it  is  applicable  to  those  cases  in  which 
only  the  superficial  and  most  exterior  fibers  of  the 
perineum  are  torn."  The  above  views  can  certainly 
be  based  only  on  imperfect  knowledge,  execution,  or 
observation  of  the  operation.  We  can  affirm  that  it 
is  one  of  the  most  certain  and  effective  of  all  opera- 
tions on  the  perineum.  The  flap  method  of  colpo- 
perineorrhaphy  is  the  one  above  all  others  that  enables 
an  operator  to  reunite  the  levator  ani  fascia  superior 
and  inferior  *with  the  enclosed  levator  ani  muscle 
without  blind  searching,  to  abolish  a  rectocele,  and  to 
repair  prolapse  of  the  uterus.  The  same  writer  cited 
above  makes  a  further  statement  as  ridiculou  s  as  the 
first,  that,  "In  no  way  possible  can  this  operation 
(flap-splitting)  narrow  the  vagina,  abolish  a  rectocele, 
or  bring  together  the  separated  fibers  of  the  pelvic 
fascia."  It  is  fortunate  that  this  "American"  text-book 
does  not  represent  the  views  of  all  Americans.  The 
flap-splitting  perineorrhaphy,  in  the  hands  of  those  who 
have  thoroughly  practised  it,  has  proved  absolutely 
that  it  will  narrow  the  vagina,  abolish  a  rectocele,  and 
bring  together  the  separated  fibers  of  the  levator  ani 
fascia  superior  and  inferior  with  the  fibers  of  the 
levator  ani  muscles.  Also  it  securely  unites  the  liga- 
menta  ischeo-perinei.     The  flap  method  is  alike  use- 


96 


THE  VAGINA   AND   PERINEUM; 


ful  in  partial  and  complete  operations,  and  in  high 
rectovaginal  dissections  does  all  that  Emmet's  does, 
with  no  denudations,  and  with  a  better  chance  of 
healing,  by  avoiding  the  infectious  atrium.  Also,  like 
Emmet's  operation,  Tait's  flap-splitting  is  founded  on 
anatomic  structures  and  designed  to  restore  physio- 
logic functions.     Both  operations  have  come  to  stay. 


Fig.  36.— A  perineal  laceration  to  the  rectum.  Two  fingers  of  the  left 
hand  are  in  the  rectum ;  the  recto-vaginal  septum  is  put  on  lateral  tension 
by  the  traction  fbrceps  on  each  side ;  the  blade  of  the  scissors  is  inserted 
between  the  rectal  and  vaginal  walls,  and  the  dotted  line  marks  out  the 
flap  to  be  produced. 

The  conception  of  the  flap-splitting  operation  rests  on 
the  pathologic  conditions  of  the  wound.  If  one  ex- 
amines a  vulva  with  lacerations,  he  will  see  linear  cica- 
trices, narrow  white  lines  which  are  transverse  in  dis- 
section. These  white  lines  are  the  healed  cicatrices 
of  the  old  perineal  lacerations     The  linear  cicatrix  is 


HOW   TO   MEND   THEM.  97 

healed  at  right  angles  to  the  original  wound  or  rent. 
Wounds  generally  heal  in  the  direction  of  the  tear. 

On  this  peculiar  condition  of  the  cicatrix  being  at 
right  angles  to  the  wouud  is  based  the  flap-splitting 
method  of  Mr.  Tait.  The  transverse  cicatrix  is  split 
and  sutured  at  right  angles  to  itself.  It  simulates  the 
Heinike-Mikulicz  pyloroplasty  when  the  wound  is 
sutured  exactly  in  the  opposite  direction  to  its  inci- 
sion. It  is  the  same  procedure  as  one  may  employ 
in  varicocele  to  shorten  the  scrotum,  i.e.,  incise  the 
scrotum  along  the  spermatic  cord  for  three  inches  and 
then  suture  the  scrotal  wound  at  right  angles  to  the 
incision  as  is  practised  in  Dr.  Senn's  clinic.  In  su- 
turing the  split  cicatricial  wound  at  right  angles  to 
itself  we  restore  exactly  the  original  normal  structures 
of  the  perineum.  By  this  method  the  perineum  and 
relations  are  restored  to  the  normal  condition,  which 
alone  will  withstand  subsequent  labors.  The  patient 
should  be  prepared  for  three  days  before  the  opera- 
tion by  cathartics,  so  that  the  digestive  tract  may  be 
thoroughly  evacuated.  The  cathartics  should  be  so 
administered  that  all  defecation  should  cease  8  to  10 
hours  before  the  operation.  There  will  then  be  no 
feces  in  the  rectum  during  the  operation  nor  for  some 
hours  subsequent.  The  patient  is  anesthetized,  and 
lies  on  the  back.  The  instruments  useful  in  this  oper- 
ation are  elbow  scissors,  a  handled  needle  with  an  eye 
in  its  pointed  end,  and  strong  silkworm  gut.  The 
silk  worm  gut  should  be  thoroughly  washed  with 
soap  and  water.  The  index  and  middle  finger  are  in- 
troduced into  the  rectum,  and  the  recto-vaginal  sep- 
tum is  divided  in  the  linear  cicatrix.  The  scissors 
point  is  then  forced  under  the  skin  of  the  labia  and 
carried  upward  as  far  as  desired  and  clipped.  The 
opposite  side  is  treated  exactly  the  same.  Back  cuts 
are  now  made  on  each  side  of  the  rectum  as  long  as 
desired.     In  slight  operations  the  back  cuts  are  not 


98 


THE   VAGINA   AND   PERINEUM; 


required.  The  anterior  vaginal  flap  is  seized  with 
forceps  and  drawn  forward,  while  the  posterior  rectal 
flap  is  seized  and  drawn  backward.  We  dissect  the 
rectum  from  the  vagina  as  high  as  desired  (IJ  to  3 
inches).    At  the  same  time  the  lateral  space  on  each 


Fig.  37.— (Modified  from  Pozzi.)  A  very  extensive  recto-vaginal  lacer- 
ation of  old  standing,  with  large  radiating  cicatricial  tissue  showing 
healing  lines.  The  scissor  blades  on  each  side  introduced  between  the 
rectal  and  vaginal  walls  at  the  cicatricial  margins  illustrate  how  the  flaps 
are  produced.  " Back  cuts"  extend  to  the  scissor  handles;  the  back  cuts 
are  made  to  produce  a  larger  perineal  body.  A  Sims'  speculum  is  inserted 
into  the  vagina,  anteriorly. 


HOW   TO   MEND   THEM.  99 

side  of  the  vagina  is  dissected  as  extensively  as  is 
required  to  make  the  perineal  body.  (See  Fig.  19) 
The  two  fingers  of  the  left  hand  are  kept  continually 
in  the  rectum  as  a  guide.  The  extent  of  the  dissec- 
tion is  governed  by  the  condition  of  the  parts,  the 
size  of  the  wound,  and  the  object  in  view;  whether  it 
be  narrowing  the  vagina,  extension  of  the  perineum, 
or  almost  closing  the  passage  for  prolapse.  With  con- 
siderable dissection,  a  few  arteries  may  need  clamp- 
ing; however,  the  hot  irrigation  will  nearly  always  be 
sufl&cient  to  check  the  hemorrhage.  If  the  bulb  be 
out  it  will  bleed  profusely,  but  sponge-pressure  will 
soon  check  it.  If  the  scissors  cut  open  a  vulvo-vagi- 
nal  abscess  the  whole  gland  should  be  dissected  out 
and  disinfected,  in  order  to  avoid  an  abscess  in  the 
wound. 

The  second  step  of  the  operation  is  to  introduce  the 
sutures  of  silkworm  gut.  The  two  fingers  are  removed 
from  the  rectum  and  well  cleaned.  The  point  of  the 
handled  needle  is  introduced  at  the  upper  angle  of 
the  wound  (No.  2  in  Fig.  21)  without  penetrating  the 
skin  or  vaginal  mucous  membrane,  carried  along 
about  one-half  inch  from  the  distal  edge  of  the  vaginal 
flap  and  made  to  emerge  at  the  median  raphe.  It  is 
then  threaded  and  drawn  out.  The  point  of  the 
needle  is  again  introduced  at  the  upper  angle  of  the 
wound  on  the  opposite  side  (No.  4  in  Fig.  21),  forced 
along  the  distal  edge  of  the  flap  about  one-half  inch 
from  the  edge  and  made  to  emerge  again  on  the 
median  line.  It  is  threaded  and  drawn  out.  This 
constitutes  the  first  suture.  Generally  three  anterior 
sutures  are  introduced  in  the  above  manner.  To 
introduce  the  posterior  sutures  (three  or  four)  the 
index  finger  should  be  placed  in  the  rectum  as  a  guide, 
to  avoid  passing  the  needle  too  close  to  the  rectal 
mucosa,  endangering  fistula.  The  fistula  may  arise 
quickly  or  slowly.     If  quickly  an  abscess  will  arise; 


100 


THE   VAGINA   AND   PERINEUM; 


if  slowly  (two  to  four  weeks)  a  fistula  will  arise  and 
remain  a  longer  or  shorter  time.  In  one  case  a  fistula 
persisted  for  three  years.  The  posterior  sutures  are 
introduced  similar  to  the  anterior.  However,  they 
should  be  deeper  and  should  thoroughly  include  the 
levator  ani  fascia  superior    and  inferior  with    the 


Fig.  38. — (Author.)  A  stage  in  progress  of  the  flap-forming  colpoperi- 
neorrhaphy.  Here  the  sutures  appear  as  if  the  process  had  started  at 
the  anus,  but  the  safest  and  most  practical  method  is  to  begin  to  intro- 
duce sutures  and  tie  from  the  anterior  end.  All  sutures  are  threaded  in 
the  median  line.  The  needle  may  be  thrust  across  the  entire  denuded 
field,  but  one  can  make  more  perfect  and  deeper  suturing  by  doing  one- 
half  at  a  time. 


HOW   TO   MEND   THEM.  101 

enclosed  levator  ani  muscle.  The  point  of  the 
needle  is  passed  into  the  edge  of  the  wound,  avoiding 
the  skin,  and  pushed  onward  to  the  median  line, 
where  the  point  emerges,  is  threaded  and  drawn  out. 
It  is  again  introduced  on  the  opposite  side  and 
threaded  in  the  middle.  In  all  cases  requiring  exten- 
sive dissection  the  needle  should  be  passed  through 
half  of  the  wound  only.  In  the  less  extensive  part  of 
the  wound  the  needle  may  pass  through  the  whole 
;^ound  at  once.  Mr.  Tait  employed  three  to  five 
sutures.     We  employ  five  to  seven  sutures. 

The  third  step  is  to  tie  the  sutures  of  silkworm  gut. 
All  the  "sutures  are  seized  at  the  distal  end  by  the  left 
hand  while^he  right  hand  pushes  the  tissues  of  the 
wound  as  far  toward  the  loop  of  the  sutures  as  possi- 
ble. This  is  a  partial  step,  as  it  narrows  and  puckers 
the  wound  very  much,  so  that  when  each  individual 
suture  is  tied  it  assumes  its  final  location.  The 
sutures  should  not  be  tied  too  tight,  as  they  are  apt 
to  cut  through  considerable  tissue.  After  the  sutures 
are  tied,  a  linear  gap  of  considerable  width  will  exist 
in  the  niedian  line,  for  the  sutures  do  not  penetrate 
the  skin,  and  hence  will  not  draw  it  in  close  coapta- 
tion. Here  some  of  the  inexperienced  will  be 
tempted  to  place  a  few  skin  sutures  to  avoid  the 
gaping  of  the  wound.  Be  sure  not  to  do  it,  for  they 
cause  pain  and  may  produce  an  abscess;  when  the 
legs  are  placed  together  the  edges  of  the  wound  will 
coapt.  The  ends  of  the  sutures  should  be  left  long 
and  all  tied  into  a  single  bundle.  The  after-treat- 
ment consists  in  applying  no  dressing  or  chemicals  to 
the  wound.  If  there  be  considerable  pain  small  hypo- 
dermic doses  of  morphin  may  be  used  for  thirty-six 
hours.  Most  patients  will  require  catheterizing,  from 
trauma  to  the  distal  ends  of  the  pubic  nerves.  After 
forty-eight  hours  we  begin  to  give  two  quarts  of  a 
vaginal  douche,  evening  and  morning.     The  bowels 


102 


THE   YAGINA   AND   PERINEUM; 


should  be  moved  on  the  third  or  fourth  day  by  means 
of  calomel  given  in  small  doses  (1  grain  two  or  three 
times)  and  followed  by  teaspoonful  doses  of  MgSOi. 
Diet  should  be  regulated  and  limited  for  three  days 
before  and  three  days  subsequent  to  the  operation. 


Fig.  39.— (Eobinson-Holland.)    Method  of  formation  of  anterior  and 
posterior  flaps  in  the  flap  method  of  executing  colpoperineorrhaphy. 

The  patient  should  lie  in  bed  for  at  least  two  weeks, 
and  afterward  get  up  as  she  is  able.  The  sutures 
should  be  watched.  If  one  becomes  loose  it  should  be 
removed.  If  none  become  ioosa  or  separate  they  may 
remain  for  three,  four  or  even  six   weeks.      Three 


HOW   TO    MEND   THEM.  .  103 

weeks  is  soon  enough  to  remove  the  sutures.  The 
wound  heals  more  firmly  with  the  sutures  in  for  four 
weeks  or  more.  The  sutures  act  like  splints,  holding 
the  surfaces  in  fixed  coaptation,  avoiding  motion, 
which  interferes  with  perfect  union.  The  sutures 
often  give  pain  on  removing,  and  it  would  perhaps 
be  better  in  some  neurotic  cases  to  anesthetize  the 
patient.  However,  I  never  practise  it.  Amateurs 
must  be  warned  not  to  close  the  vulva  unnaturally 
tight  as  it  might  disturb  marital  relations.  The  cuts 
in  the  article  will  show  the  steps  in  the  technique. 

THE   EMMET   OPERATION. 

This  operation  is  in  marked  contrast  to  all  previous 
ones  for  similar  purposes,  as  union  of  the  denuded 
labia  was  the  first  procedure.  The  peculiarity  of 
Emmet's  operation  consists  in  denudation  of  the  lower 
median  posterior  vaginal  wall;  bilateral  denudation 
of  triangular  portions  of  the  lateral  sulci  of  the 
vagina;  in  the  method  of  introducing  the  sutures, 
which  are  so  arranged  that  on  tying  they  lift  the  pro- 
lapsing parts  toward  the  pubic  arch,  restoring  ana- 
tomic structures,  as  the  H-shape  to  the  vagina  and  the 
normal  curve  of  the  vagina.  The  patient  should  be 
prepared  for  several  days  by  cathartics  and  daily  skin 
baths.  The  bowels  should  be  evacuated  by  eight  to 
twelve  passages,  so  that  no  feces  will  be  in  the  rectum 
while  operating,  nor  for  24  to  36  hours  after.  Thor- 
ough salt  rubbing  of  the  skin  not  only  stimulates  the 
apparatus  of  the  skin  to  the  climax  of  secretion  but 
reflexly  stimulates  the  bowels  and  kidneys  to  active 
secretion.  In  short,  place  all  secretory  organs — skin, 
bowel  and  kidney — at  their  maximum  activity  for  the 
operation.  Place  the  anesthetized  patient  on  the 
back,  with  an  assistant  holding  each  limb,  With 
tenacula  fixed  to  definite  points  of  the  vagina,  as  for 
example,  one  at  the  median  crest  of  the  rectocele,  one 


104 


THE   VAGINA   AND   PERINEUM; 


tenaculum  on  each  side  of  the  vagina  at  the  highest 
point  of  the  triangle  of  denudation  in  the  sulci  and 
one  on  each  side  of  the  posterior  vaginal  wall  at  the 
junction  with  the  skin  and  mucosa,  one  can  mark 
the  outline  of  the  denudation  with  a  scalpel.  It  is 
well,  before  denudation,  to  test  whether  the  area  is 
too  large  to  insure  coaptation  of  the  wound  without 
undue  tension.     The  area  defined  by  the  tenacula  is 


Fig.  40,— (Robinson-Holland.)  Method  of  introducing  the  sutures  in 
the  flap  method  of  colpoperineorrhaphy.  Note  that  the  handled  needle 
is  threaded  in  the  median  line.  This  cut  was  drawn  from  a  photograph 
taken  of  a  patient  during  the  operation. 

denuded  by  the  operator  cutting  off  long  strips  of 
vaginal  mucosa  with  scissors  curved  on  the  flat. 
Others  denude  with  the  scalpel,  rolling  the  denuded 
vaginal  flap  on  a  staff  or  on  the  fingers.  With  expe- 
rience, large  areas  may  be  rapidly  denuded.  The  area 
requiring  denudation  in  the  lateral  sulci  depends  on 
the  amount  of  slack  in  the  posterior  vaginal  wall,  for 


HOW   TO   MEND   THEM.  105 

this  operation  has  the  special  merit  of  narrowing  the 
vaginal  canal.  With  a  typically  relaxed  vaginal  out- 
let a  large  area  of  denudation  will  be  required,  and 
especially  high  in  the  right  and  left  vaginal  walls. 
The  denudation  should  consist  of  the  whole  thickness 
of  the  vaginal  wall.  Continuous  hot  water  irrigation 
over  the  denuded  surface  will  check  the  hemorrhage. 
The  operation  is  eminently  a  posterior  colporrhaphy, 
and  the  success  will  depend  on  denudation  in  the 
lateral  vaginal  sulci,  and  not  on  the  denudation  of  the 
so-called  perineum.  In  case  the  vaginal  wall  is  very 
slack  and  thin  it  is  well  to  extend  the  denudation  deep 
into  the  bilateral  subvaginal  tissue  in  the  vaginal 
sulci.  Perfect  denudation  is  a  requisite;  no  islands 
of  vaginal  mucosa  must  be  left.  The  second  step  of 
the  operation,  equally  important  with  denudation,  is 
the  plan  erf  introducing  the  sutures.  The  object  of 
the  special  planning  of  the  sutures  is  to  lift  the  lax 
vaginal  outlet  upward  toward  the  pubic  arch,  restor- 
ing the  vaginal  condition.  The  skill  in  planning  the 
denudation  in  the  right  and  left  sulci  of  the  vagina  is 
no  less  than  that  employed  in  the  introduction  of  the 
well-devised  plan  of  sutures,  The  chief  materials  for 
sutures  are  silver  wire,  silkworm  gut,  and  catgut.  To 
suture  the  denuded  surface  expose  one  of  the  triangles 
in  the  lateral  vaginal  wall.  Begin  to  suture  at  its 
apex,  passing  the  suture  transversely  across  the  angle, 
after  which  immediately  tie  it.  The  second  suture  is 
passed  one -quarter  of  an  inch  from  the  first  (four 
sutures  to  the  inch).  The  needle  is  passed  through 
the  vaginal  wall  and  subvaginal  tissue  toward  the 
operator  (in  an  anterior  posterior  direction),  whence 
it  emerges,  and  is  re-entered  at  the  same  point  and 
passed  in  an  antero-posterior  direction  under  the  sub- 
vaginal tissue  through  the  denuded  triangle,  emerg- 
ing on  the  vaginal  mucosa  at  the  edge  of  the  wound. 
This  makQs  the  suture,  before  tying,  represent  a  tri- 


106 


THE   VAGINA   AND   PERINEUM; 


angle,  with  its  apex  (at  the  emerged  points  of  the 
suture  in  the  denuded  triangle)  toward  the  operator, 
and  characterizes  the  plan  of  suturing;  i.  e.,  they  are 
introduced  in  an  antero-posterior  direction,  and  by 
tying,  they  lift  the  vaginal  outlet  toward  the  pubic 
arch.  The  next  suture  is  introduced  by  passing  the 
needle  through  the  vaginal  wall  (on  the  internal  side 


Fig.  41.— (Author.)  Diagram  of  the  plan  of  Tait's  flap  colpoperineor 
rhaphy :  a,  S,  sacrum ;  R,  rectum ;  P,  intact  perineal  body ;  V,  vagina,  with 
urethra  above  it ;  &,  has  had  the  torn  perineal  body,  P,  repaired  by  the  six 
sutures  marked  by  stars ;  c,  shows  the  H-shaped  anterior  cuts,  a,  6 ;  c,  (/, 
the  posterior  cuts ;  R,  rectum ;  V,  vagina. 

of  the  triangle)  deep  into  the  subvaginal  tissue  of  the 
denuded  triangle  (directly  toward  the  operator), 
whence  it  emerges,  and  is  re-entered  at  the  same 
point  and  carried  upward  and  outward  (away  from  the 
operator)  very  deeply  under  the  denuded  area,  emerg- 


HOW   TO   MEND    THEM.  107 

ing  on  the  vaginal  mucosa  at  the  external  side  of  the 
triangle.  The  sutures  on  the  external  side  of  the 
denuded  triangle  should  be  especially  deep  and  should 
include  extensive  tissue.  Generally  three  or  four 
sutures  are  sufficient  to  close  the  triangle  of  each  sul- 
cus. The  suture  at  the  base  of  each  triangle  may  be 
called  a  tension  suture.  It  can  be  tied  as  soon  as 
passed,  which  will  enable  more  superficial  sutures  to 
be  applied  to  the  upper  part  of  the  triangle.  The 
crown  or  pursing  suture  is  now  passed  within  the 
vagina  by  introducing  the  needle  in  the  mucosa  on 
the  lateral  vaginal  wall  close  to  the  incision,  a  short 
distance  below  the  center  of  the  triangle.  The  needle 
should  emerge  in  the  subvaginal  tissue  in  the  sulcus 
below  the  point  of  introduction.  The  needle  is  re- 
entered and  carried  across  the  vaginal  sulcus  just 
below  the  vaginal  incision,  emerging  at  the  opposite 
side.  One  or  two  auxiliary  pursing  sutures  are  added 
and  the  several  sutures  tied;  superficial  sutures  are 
then  added,  as  required,  to  close  the  gaps  in  the 
wound.  The  deep  sutures  should  be  of  silkworm  gut 
and  the  superficials  of  catgut. 

In  this  essay  it  is  not  the  purpose  to  discuss  imme- 
diate repair  after  labor,  but  the  views  are  directed 
toward  chronic  damage  of  the  vulva,  vagina  and  pelvic 
floor.  It  will  require  careful  examination  of  the 
vulva,  vagina  and  uterus  to  decide  in  certain  cases 
what  will  be  the  wisest  plan  to  pursue.  Some  cases 
show  extensive  laceration  with  but  .few  symptoms, 
while  others  show  little  damage,  but  complain  of 
severe  suffering.  Such  differences  rest  on  visible 
and  invisible  supports.  Extensive  perineal  lacera- 
tions demand  repair  whether  they  create  symptoms  or 
not,  as  such  lesions  will  in  all  probability  lead  to  ill- 
ness. One  may  occasionally  meet  a  patient  who  has 
had  a  perineal  operation,  and  the  perineum  to  all 
intents  and  purposes  appears  normal ;  yet  an  exami- 


108 


THE   VAGINA   AND   PERINEUM; 


nation  reveals  the  fact  of  a  reotocele  above  the  restored 
perineal  body,  and  the  patient  confirms  the  results  of 
the  examination  by  still  announcing  herself  as  suffer- 
ing. In  operating,  the  dissection  of  the  so-called 
perineal  body  should  extend  as  high  on  the  recto- 


Fig.  42.— The  outlines  of  the  anterior  "cuts,"  (A,  E,)  and  posterior 
'*cuts"  (A,  B,)  in  the  flap  colpoperineorrhaphy.  to,  Clitoris;  /i,  urethra; 
L,  P,  anterior  vaginal  wall ;  A,  N,  anus ;  N,  R,  perineum ;  E,  C,  labia.  The 
vaginal  orifice  is  wide  open.  The  laceration  is  not  complete,  i.e.,  it  does 
not  reach  the  rectum, 

vaginal  septum  as  there  appears  redundancy  of  the 
posterior  vaginal  wall  (rectocele).  Nothing  less  will 
cure  the  patient.  The  perineal  body,  in  its  broadest 
sense,  is  a  resistant  ligamentous,  fibromuscular  struo- 


HOW   TO   MEND   THEM.  109 

ture  which  closes  the  abdominal  cavity  below.  The 
body  begins  to  be  supported  from  the  curved  white 
line  located  on  each  side  of  the  pelvis,  as  one  may  be 
impressed  by  looking  into  a  pelvis  from  above.  It  is 
bowl-shaped,  and  as  soon  as  this  peculiar  shape 
becomes  lost,  the  supports  have  given  away  at  some 
point.  Observed  from  below  the  perineum  is  nar- 
rowed to  the  space  between  rectum  and  vagina.  The 
flap  operation  is  capable  of  repairing  any  defect  in 
the  pelvic  floor.  In  complete  laceration  the  anal  and 
vulvar  orifices  are  in  direct  communication,  like  a 
cloaca.  The  rectovaginal  septum  may  show  a  boot- 
jack angle  or  an  irregular  arched  outline.  The  irreg- 
ularly-torn outline  of  the  rectovaginal  septum  shows  a 
double-walled  layer  or  curved  sides.  At  the  upper 
angle  of  the  lacerated  rectovaginal  septum  the  rectal 
mucosa  pouts,  rolls  and  appears  as  a  red  or  pink 
ground  which  aids  in  locating  the  line  to  split  the 
flaps. 

After  the  rectovaginal  septum  has  been  lacerated 
for  a  long  time  it  presents  irregular  cicatricial  bands, 
some  of  which  are  thin,  others  thick,  assuring  differ- 
ent stages  of  atrophy  and  contraction.  Bridges  or 
bands  of  tissue  may  stretch  from  one  point  to  another 
showing  a  penetrated  condition.  Again,  the  lower 
edges  of  the  lacerated  rectovaginal  septum  may  be 
drawn  upward  by  the  fibers  of  the  levator  ani  still 
embracing  the  parts  by  the  aid  of  its  double  fascial 
sheets.  Besides  small,  irregular  depressions  may  be 
felt  or  observed  where  the  stump  of  a  bundle  of  the 
levator  muscles  has  been  torn  away  and  retracted. 
The  deep  sutures  applied  after  splitting  the  septum 
will  include  these  stump  ends  of  the  muscles  by  means 
of  fascia  so  that  they  may  be  again  forced  to  the 
median  raphe  and  fixed  there.  The  flap  operation 
does  not  need  to  observe  whether  the  sphincter,  anus 
or  rectovaginal  septum  be  lacerated,  for  it  is  alike 


110 


THE   VAGINA   AND   PERINEUM; 


applicable  to  each  and  all.  On  examination  we  may 
find  all  kinds  of  associated  conditions  with  extensive 
colpoperineal  lacerations,  as  lacerated  cervix,  subin- 
volution of  the  vagina,  cystocele,  rectocele,  and  retro- 
version of  the  uterus.    Now  if  the  uterine  appendages 


Fig.  43.— Dissection  of  the  flap  and  the  anterior  vaginal  wall,  N,R, 
drawn  up  with  forceps.  The  posterior  flap,  S,  is  drawn  backward  by  for- 
ceps, two  sutures,  6,  n,  are  already  passed ;  three  more  sutures,  one  being 
introduced  by  passing  the  curved-handled  needle  from  the  lateral  edge  of 
the  wound  to  the  middle  of  the  denuded  surface  and  threading  it  from 
the  median  line  with  silkworm  gut ;  D,  I,  anus ;  V,  perineum ;  E,  clitoris ; 
X,  urethra ;  L,  P,  anterior  vaginal  wall. 


HOW   TO   MEND   THEM. 


Ill 


are  freely  movable  we  can  generally  cure  the  patient 
by  curettement,  repair  of  the  cervix  and  colpoperineor- 
rhaphy,  for  much  of  the  disease  observed  is  du6  to 
disturbed  circulation.  The  vessels  have  been  torn 
from  their  supporting  bed  by  the  deranged  fascia. 
The  veins  have   become    straightened  out,  dilated 


Pig.  44.— Sutures  tied  in  the  operation  for  colpoperineorrhaphy  with 
incomplete  laceration.  A,  N,  anus;  L,  M,  labia;  A,  clitoris;  V,  urethra: 
E,D,  median  line  of  the  peripeal  raphe;  P,  posterior  point  of  perineal 
space. 

locally,  and  have  lost  their  elegant  spiral  form,  result- 
ing in  blood  stasis,  congestion.  Restore  the  supports 
and  circulation  will  resume. 

The  diagnosis  consists  of  observation  and  palpa- 


112  THE   VAGINA   AND   PERINEUM; 

tion  with  the  aid  of  a  large  Sims  speculum.  In  the 
diagnosis  a  notably  striking  feature  is  the  changed 
appearance  of  the  vulvar  outlet.  Normally  the  peri- 
neum is  widest  at  its  upper  end.  With  lacerated 
perineum  or  relaxed  vulva  the  whole  external  appear- 
ance is  changed.  The  narrow  puckered  chink  or  slit- 
like  aperture  of  the  natural  vulvar  orifice  is  trans- 
formed into  a  patulous  gaping.  Again,  the  normal 
vagina  presents  a  sigmoid  curve  with  the  posterior 
vaginal  wall  coapting  and  embracing  the  anterior,  like 
a  valve.  But  in  deficient  vaginal  apparatus  these 
two  concentric  coapted  curves  have  lost  their  rela- 
tions, especially  the  posterior  vaginal  curve.  It  should 
be  remembered,  in  diagnosing  this  deficiency  at  the 
vulva,  that  the  non-closure  is  not  due  especially  to 
loss  of  the  perineal  body,. but  to  defect  in  the  levator 
,  ani  muscle  and  its  double  fascial  layers.  The  levator 
ani  muscle  endows  the  rectum  with  its  anterior  curve 
and  drags  the  lower  end  of  the  vagina  upward  and 
forward  against  the  pubic  arch.  This  fact  can  be 
demonstrated  by  introducing  the  finger  into  the  vag- 
ina and  forcing  backward  and*  downward,  when  by 
removing  the  finger,  the  vagina  quickly  returns  to  its 
normal  position.  The  vaginal  orifice  has  no  distinct 
sphincter  like  the  mouth  or  anus,  but  has  an  indirect 
sphincter,  the  horseshoe  loop  of  the  levator  ani,  aided 
by  the  pubic  arch.  The  arch  acts  like  a  fixed  point 
and  the  vagina  is  indirectly  closed  by  shortening,  con- 
tracting of  the  anterior  bundle  of  the  levator  ani 
muscle.  The  vagina  is  closed  by  flattening  its  walls 
antero-posteriorly  between  the  rectum  and  pubic  arch. 
It  is  H-shaped.  There  is  a  slight  puckering  of  the 
vagina  at  its  external  orifice  by  means  of  the  weak 
bulbo-cavernosus  muscle,  but  practically  this  amounts 
to  nothing  in  physiology  and  anatomy.  On  account 
of  the  position  of  the  rectum  in  relation  to  the  leva- 
tor muscle  it  produces  a  sigmoid  curve  to  the  rectum, 


HOW   TO   MEND   THEM. 


113 


with  its  convexity  forward.  This  is  due  to  the  fact 
that  the  strongest  bundles  of  the  levator  muscle  encir- 
cle the  rectum  about  an  inch  above  its  orifice  or  lower 
end,  whence  by  contraction  it  yields  at  the  point  of 
greatest  force,  i.  e.,  at  the  sigmoid  bend.     On  account 


Figr.  45,— Flap  formation  in  a  case  of  complete  laceration  of  the  recto- 
vaginal septum  into  the  rectum.  The  scissor  blade  is  splitting  the  vaginal 
from  the  rectal  wall  to  form  the  flap,  F,  whose  margin  comes  from  the 
mucocutaneous  line  X,  P;  P,  P,  is  the  back  cut;  A  to  A,  the  opposite  back 
cut;  A,  M,  the  anterior  scissor  clip, 

of  the  position  of  the  vagina,  levator  ani  and  pubic 
arch,  the  lower  end  of  the  vagina  is  dragged  upward, 
producing  its  sigmoid  curve  forward,  in  the  opposite 


114         THE  VAGINA  AND  PERINEUM; 


direction  to  that  of  the  rectum.  In  other  words,  the 
plane  of  the  pubic  arch  is  anterior  to  the  plane  of  the 
levator  ani  muscle,  and  when  it  contracts  it  must  nec- 
essarily drag  the  lower  end  of  the  vagina  upward  and 
forward.  These  considerations  may  be  appreciated 
by  introducing  the  finger  into  the  vagina  and  the 
thumb  into  the  rectum.  It  is  best  studied  first  on  a 
multipara  and  second  on  a  nullipara,  and  third  on  one 
with  a  deficient  vaginal  sphincter  apparatus.  The 
closure  of  the  vagina  well  forward  toward  the  pubic 
arch  produces  a  kind  of  valve,  which  acts  almost  as  a 
certainty  against  prolapse  while  intact.  This  is  one 
of  the  elements  of  success  in  both  the  Emmet  and 
Tait  perineal  operations.  The  vast  difference  in 
appearance  between  the  virgin  and  the  relaxed  vaginal 
sphincter  apparatus  of  the  multipara  is  due  to  the 
yielding  of  supports  by  the  process  of  labor  in  nearly 
all  cases  (visceral  ptosis  excepted).  This  does  not 
appear  so  strange  when  we  consider  that  the  virginal 
passage  of  the  vagina  is  about  an  inch  in  diameter, 
while  the  passing  head,  shoulders  and  breech  demand 
ten  to  twelve  inches  in  diameter.  It  is  not  strange 
that  tissues  forced  to  stretch  from  one  to  twelve  inches 
should  forget  to  return.  The  levator  ani  muscle  is 
arranged  in  fasciculi  or  bundles,  or  it  would  become 
defective  more  frequently.  The  sphincter  and  vaginal 
apparatus  may  be  injured  by  external  accidental 
trauma,  but  labor  is  the  chief  factor. 

Relaxed  vaginal  outlet,  concealed  lacerations  or 
deep  musculo-fascial  tears  of  the  pelvic  floor,  can  not 
be  too  forcibly  brought  to  the  notice  of  the  physician 
as  an  important  diagnostic  indication  for  colpoperine- 
orrhaphy.  Kelly  calls  such,  concealed  relaxation. 
This  is  a  condition  of  loose,  gaping  vulva,  compared 
to  the  mouth  of  a  bag  without  its  puckering-string  by 
Dr.  Emmet.  If  the  patient  lie  on  the  back  the  fork 
of   the   buttocks  looks   flattened,   the   anus   appears 


HOW   TO   MEND   THEM. 


115 


everted,  and  one  may  observe  the  vaginal  mucosa 
bulging  out  above  or  below.  The  condition  is  fre- 
quently described  as  rectocele  or  cystocele,  or  both. 
Others  call  it  perineal  laceration.  Some  will  write 
that  it  can  not  be  perineal  laceration,  because  the  skin 
perineum  is  longer  than  the  normal  one.  The  skin 
perineum  is  longer  than  normal  because,  when  it  was 
stretched  at  labor,  it  never  returned  to  normal  (sub- 


Fig.  46.— Advanced  stage  of  the  flap-splitting  operation.  L,  V,  anterior 
vaginal  flap  held  up  by  forceps ;  the  posterior  rectal  flap  is  held  backward 
by  forceps ;  the  most  posterior  suture  is  placed  along  the  margin  of  the 
torn  rectum ;  other  sutures  are  being  introduced  by  being  threaded  in  the 
median  line  and  drawn  out.  Note  that  the  needles  do  not  penetrate  the 
ekin  or  mucosa. 


116 


THE   VAGINA   AND   PERINEUM; 


involution).  Occasionally  one  can  introduce  the  four 
fingers  of  the  hand  and  put  the  long  relaxed  perineum 
on  a  stretch.  It  is  in  these  long,  lax  skin  perinei  .that 
physicians  disagree  as  to  conditions,  the  one  asserting 
that  the  perineum  is  plenty  large  enough  and  does 
not  require  an  operation,  while  the  other  rightly  asserts 
that  the  perineum  is  but  a  small  part  of  the  support 
of  the  sexual  organs.  The  fact  is,  the  whole  vagina 
and  sphincter  apparatus  has   become  deficient,  the 


Fig.  47.— Another  stage  of  flap  forming.  Observe  that  the  most  pos- 
terior suture  is  being  introduced  by  the  needle  passing  from  one  side  of 
the  denuded  wound  to  the  other,  because  the  space  is  short,  but  the 
denuded  surface  under  the  flap  is  generally  so  wide  that  it  is  most  prac- 
tical to  pass  the  handled  needle  from  the  lateral  margin  of  the  wound  to 
the  median  line,  where  the  needle  is  allowed  to  emerge  and  become 
threaded.  Thus  the  sutures  are  passed  through  half  of  the  wound  at  one 
time. 


HOW    TO    MEND    THEM. 


117 


yulva  pouts,  the  anus  everts,  and  the  floor  of  the  pel- 
vis flattens  out.  If  the  patient  is  requested  to  bear 
down,  the  anterior  and  posterior  vaginal  walls  will  roll 
outward,  often  to  an  astonishing  degree.  By  the  act 
of  straining,  the  cervix  can  be  felt  descending.  The 
patient  has  utero-ptosis.     The  sacro-pubic  hernia  is 


^*iijfe>-' 


Fie  48  —Finished  operation  in  a  case  of  complete  .laceration.  R,  L, 
anterior  end,  and  A,  F,  posterior  end  of  newly-built  perineal  raphe;  A,  N, 
ossus  ani  is  a  little  patent. 

more  marked  if  one  examines  the  patient  in  the  stand- 
ing position.  By  careful  inspection  and  palpation 
while  the  patient  lies  on  the  back,  one  may  feel  the 
retracted  cicatricial  stump  ends  of  the  lacerated  levator 
ani  muscle,  and  by  irritating  the  little  cicatricial  ele- 
vated  or  depressed  stumps  we  can  see  the  contractions 


118 


THE  VAGINA  AND   PERINEUM; 


and  relaxations  in  them.  Sometimes  the  perineum 
or  lower  posterior  vaginal  wall  is  so  relaxed  that  it 
is  large  enough  to  close  up  the  vulva  like  a  valve. 
The  horseshoe  loop  of  the  levator  ani,  which  extends 
from  one  pubic  ramus  to  the  other,  presents  no  more 
the  resisting,  broad,  elastic  loop  felt  in  the  virgin,  but 
in  the  middle  one  feels  an  irregular  sharp  edge  of 


Fig.  49.— (Author.)    Method  of  forming  the  flaps  with  a  non-complete 
laceration,  with  anterior  and  posterior  "cuts"  and  vaginal  flap. 

narrow  dimensions.  Also  the  loops  of  the  levator  are 
more  displaced  to  the  side  of  the  vagina.  Though 
the  patient  can  generally  control  stool,  yet  the  vigor- 
ous elasticity  of  the  muscular  loop  is  definitely  im- 
paired. With  the  patient  on  the  back  and  the  two 
index  fingers  in  the  vagina,  one  can  quickly  test  the 
degree  of  deficiency  of  the  sphincter  vaginal  appara- 
tus by  pressing  downward  and  backward.     The  vulva 


HOW   TO   MEND   THEM.  119 

may  pout  with  perineal  skin  intact,  and  the  same  may 
be  said  of  the  rectum.  The  fascia  and  levator  ani 
may  be  quite  defective  on  one  side  and  intact  on  the 
other  side.  In  very  sensitive  women,  made  worse  by 
long-continued  irritation,  the  examination  is  occasion- 
ally delusive,  because  reflex  irritation  puts  parts  on  a 
tension. 

We  may  classify  the  operations  for  colpoperineor- 


_  Fig.  50.— (Eobinson-Sclaoler,)  The  flap  formation.  On  the  right  the 
scissors  are  shown  forming  the  anterior  "cut ;"  on  the  left  the  blade  of  the 
scissors  only  is  shown,  forming  the  posterior  '"cut"  beside  the  rectum. 

rhaphy  into  three  general  divisions,  viz.:  posterior 
median  oolpoperineorrhaphy,  posterior  bilateral  colpo- 
perineorrhaphy,  and  the  posterior  flap  oolpoperineor- 
rhaphy. Some  of  the  principal  originators  and  advo- 
cates of  posterior  median  oolpoperineorrhaphy  were 
Dieffenbach,  Langenbeck,  Baker-Brown,  Osiander, 
Simon,  Hegar,  Hildebrandt,  Jobert,  DeLam  belle,  Le 
Fort,   Sohjoeder,  Werth  and  Reamy. 


120 


THE   VAGINA   AND   PEKINEUM; 


The  chief  originators  and  promoters  of  bilateral 
colpoperineorrhaphy  are  Emmet,  Staude,  Freund, 
Martin,  Bischoff,  Groodell  and  Kelly.  Some  of  the 
pioneer  originators  and  advocates  of  the  posterior  flap 
colpoperineorrhaphy  were  Langenbeck,  Duncan,  Tait, 
Jenks,  Voss,  Simpson,  Marcy,  Colles,  Sanger. 

Whatever  the  apparent  differences  of  the  above 
three  classes  of  procedure,  all  the  advocates  praoti- 


Fig.  51.— (Robinson-Scholer.)  Flap  formation  with  the  scissors  at  the 
bottom  of  gutter  between  rectal  and  vaginal  flaps.  1, 1,  vaginal  flaps  held 
aside  by  the  shepherd's  crooks,  6,  6;  2,  2,  rectal  flaps;  3,  3,  "back  cuts;"  4, 
rectal  lumen ;  5,  outline  of  cervix.  Tnis  represents  a  complete  laceration 
high  up  into  the  rectum. 

cally  agree  that  definite  denudation  (flap  or  other- 
wise )5  exact  approximation  of  wound  surfaces,  and 
deep  sutures  (without  tension),  based  on  anatomic 
lesions,  are  the  prerequisites  of  success.  Methods 
and  modifications  are  not  so  important  as  attention  to 
anatomic  and  surgical  principles.     The  physiology  of 


HOW    TO    MEND    THEM. 


121 


structure  being  disturbed  by  an  overstretched  peri- 
neum or  elongated  supports  (enteroptosis),  it  must 
be  restored  by  reproducing  as  near  as  possible  ana- 
tomic integrity. 

The  relaxed  tissue  must  be  corrected  with  deep 
sutures  and  dissection;  the  blood-vessels  must  have  a 
definite  supporting  bed  in  which  to  functionate;  the 
peripheral  nerves  must  be  protected  against  continued 


Fig.  52.— (Robinson-Scholer.)  The  sutures  in  position  in  a  case  of 
laceration  high  up  into  the  rectum.  1, 1,  the  vaginal  flaps  held  aside  by 
the  shepherd's  crooks,  6,  6;  2,  2,  rectal  flaps  held  in  place  by  the  crooks, 
7,  7 ;  8,  8,  points  to  the  line  or  angle  of  junction  between  the  rectal  and 
vaginal  flaps. 

repeated  trauma,  and  the  organs  must  assume  a  nor- 
mal position,  all  of  which  belongs  to  the  domain  of 
colpoperineorrhaphy.  The  genius  of  Emmet  estab- 
lished the  utility  of  surgical  procedure  in  the  vaginal 
sulci.  The  grand  operations  of  Bischoff  sparing  the 
posterior  vaginal  column  (or  median  vaginal  surface) 
foreshadowed  and  aided  Emmet,  as  well  as  the  schol- 


122 


THE   VAGINA   AND   PERINEUM; 


arly  labors  of  Schatz  on  the  pelvic  floor.  As  a  pupil 
of  A.  Martin  in  1884,  I  saw  the  contemporaneous  and 
independent  development  of  Emmet's  operations  in 
the  vaginal  sulci,  in  the  hands  of  the  most  skilled 
gynecologic  surgeons  of  Germany. 

It  may  be  remembered  that  the  Emmet  and  Tait 
operations  are  alike  valuable  in  operations  for  relaxed 


Fig.  53. — (Robinson-Scholer.)  A  case  not  ruptured  into  the  rectum,  in 
which  the  sutures  are  in  position.  The  sutures  are  threaded  from  the 
median  line,  as  seen  in  the  cut.  Observe  that  the  sutures  penetrate  neither 
skin  or  mucosa. 

vaginal  outlet,  with  the  advantage  in  the  Tait  opera- 
tion of  a  flap  to  protect  the  wound.  The  reason  Em- 
met's operation  is  about  of  equal  value  is  that  healing 
in  the  vaginal  sulci  is  almost  certain,  hence  but  little 
danger  of  loss  of  valuable  tissue  by  non- healing. 
Nothing  is  gained  by  denuding  an  area  of  vagina  over 


HOW   TO    MEND    THEM. 


123 


retaining  that  same  area  intact,  for  it  will  contract  to 
its  original  size  shortly  after  the  tension  which  pro- 
duced it  is  removed. 

The  rational  symptoms  resulting  from  lacerations 
requiring  colpoperineorrhaphy  are  very  numerous  and 
varied,  but  they  follow  a  logical  sequence.  In  general 
the  chain  of  symptoms  is  as  follows:  A  local  point 
of  irritation — an  infection  atrium;  reflex  irritation 
which  unbalances  the  other  viscera  (abdominal  and 


Fig.  54.- 
laceration. 


-(Robinson-Scholer.)    Completed  operation  on  an  incomplete 
Five  sutures  were  employed. 


thoracic).  The  irritation,  from  a  focal  point,  travels 
up  the  hypogastric  plexus,  the  ovarian  plexus  and  the 
lateral  chain  of  sympathetic  ganglia  to  the  abdominal 
brain  and  thoracic  plexus,  which  aids  in  disturbing 
the  visceral  rhythm.  Anatomic  facts  must  be  in- 
spected. We  find  on  each  side  of  the  uterus  a  large 
ganglion,  a  massive  collection  of  nerve- cells  which 
has  been  termed  the  cervico- uterine  ganglion.  We 
may  call  it  the  pelvic  brain.     An  enormous  mass  of 


124 


THE   VAGINA   AND   PERINEUM; 


nerve-cells — the  abdominal  brain — is  found  at  the  root 
of  the  celiac  axis,  just  behind  the  stomach.  Three 
great  ganglionic  masses  of  nerve-cells  are  found  in 
the  neck  (superior,  inferior  and  middle  cervical  gan- 
glia), and  a  vast,  intricate  network  of  nerves  in  the 
heart — Wrisberg's  plexus.  Each  of  these  large  gan- 
glionic nerve  masses  is  in  intimate  and  close  commu- 


Fig.  55.— (Robinson-Scholer.)  First  stage  of  Dr.  Emmet's  operation, 
■via. :  Denudation  of  the  posterior  vaginal  wall ;  denudation  of  a  triangle 
in  each  sulci  of  the  vagina,  with  the  noted  method  of  his  peculiar  suturing. 

nication  with  the  genital  organs.  Many  strands  of 
nerves  connect  each  ganglion  with  the  pelvic  viscera. 
It  is  the  numerous  nerve  strands  which  play  the 
important  role,  because  many  strands,  tracts,  will  carry 
many  messages,  and  a  few  ganglion  cells  can  take 
care  of  innumerable  peripheral  reports.  A  few  gan- 
glion cells  will  receive  and  dispose  of  many  messages 
from  many  lines.     Now  the  ganglion  cells — the  tho- 


HOW    TO    MEND    THEM. 


125 


racic,  abdomiDal  and  pelvic  brains — assume  a  certain 
control  over  the  rhythm  of  their  respective  viscera. 
Hence  the  viscus  which  is  the  most  intimately  con- 
nected to  those  three  brains  by  many  nerve  strands 
will  exercise  significant  power  over  the  rhythm  of  the 
organs.  One  of  the  chief  functions  of  a  viscus  is 
rhythm.  If  this  be  disturbed  the  organ  becomes 
defective  and  fails  in  its  final  object. 


Pig.  56. — (Robinson-Scholer.)  Another  stage,  in  which  the  triangle  in 
the  right  vaginal  sulcus  is  closed  with  two  sutures ;  sutures  in  position. 

Let  it  be  remembered  that  the  irritation  from  a  dis- 
eased organ  is  emitted  at  all  times,  without  regard  to 
physiologic  rhythm  by  which  the  organ  accomplishes 
its  mode  of  life.  The  occasion  of  rhythm  is  the  nat- 
ural stimulus  of  an  organ,  as  food  for  the  digestive 
tract,  air  for  the  lungs,  blood  on  the  endocardium, 
urine  in  the  urinary  tract,  a  fetus  in  the  uterus,  fluids 
in  the  Fallopian  tubes,  and  food  material  in  the  liver, 


126 


THE   VAGINA   AND   PERINEUM; 


carried  to  it  by  the  portal  vein.  If  we  follow  a  dis- 
eased message  emitted  from  the  pathologic  genitals 
up  to  the  abdominal  brain  over  the  lateral  chain — the 
hypogastric  ovarian  plexus — where  it  is  reorganized 
and  emitted  to  the  digestive  tract,  we  may  observe 
the  following  disturbances:  Excessive  secretion  in 
the  digestive  traci;  deficient  secretion;  disproportion- 
ate secretion.  Excessive  secretion  may  induce  diarrhea; 


Fig.  57.— (Eobinson-Scholer.)    The  two  denuded  triangles  closed  by 
sutures ;  the  remaining  sutures  in  situ. 

deficient  secretion,  constipation;  and  disproportionate 
secretion  may  produce  fermentation  (bloating);  the 
continuation  of  such  reflex  factors  institutes  indiges- 
tion. The  reflex  irritation,  passing  from  the  diseased 
genitals  to  the  abdominal  brain,  is  reorganized  and 
transmitted  to  the  liver  over  the  hepatic  plexus.  This 
pathologic  irritation  produces   excessive,  dispropor- 


HOW   TO   MEND   THEM. 


127 


tionate  or  deficient  secretion  in  the  liver.  The  liver 
secretes  bile,  glycogen  and  urea.  It  has  a  rhythm,  just 
as  the  heart  or  lungs. 

The  transmission  of  pathologic  irritation — reflex 
irritation — to  the  liver  unbalances  its  rhythm  and  dis- 
turbs its  secretion.  If  the  rhythm  of  any  organ  be 
disturbed  its  function  will  soon  become  defective. 
For  example,  the  rhythm  of  the   small  intestines  is 


Fig.  58.— (Robinson-Scholer.)    Operation  finished.    The  Y-shaped  line 
shows  the  line  of  suturing. 

governed  by  the  superior  mesenteric  ganglion,  which 
induces  a  rhythm  four  to  six  times  daily,  according 
to  food  indigestion.  Improper  foods,  disturbing  the 
regular  rhythm,  soon  induce  indigestion.  The  de- 
scending colon,  sigmoid  and  rectum  (the  fecal  reser- 
voir) is  controlled  by  the  inferior  mesenteric  ganglion, 
which  makes  a  daily  rhythm.     The  superior  mesen- 


128         THE  VAGINA  AND  PERINEUM; 

terio  ganglion  has  a  four-  to  six-hour  rhythm,  while 
the  inferior  mesenteric  ganglion  has  a  24-hour  rhythm. 
Any  one  knows  that  disturbing  the  rhythm  causes 
constipation,  and  eventually  many  neurotic  symptoms 
arise.  Long-continued  indigestion  produces  malnu- 
trition. Pathologic  irritation  passes  to  viscera  at  all 
and  any  times,  in  season  and  out  of  season,  day  and 
night,  while  organs  are  attempting  to  rest  or  to  pass 
through  a  rhythm,  always  causing  disturbances.  Or- 
gans secure  rest  and  repair  between  rhythms. 

Malnutrition  is  followed  by  anemia — a  disproportion 
between  the  blood-vessels  and  plasm.  Long  continued 
anemia  is  followed  by  neurosis.  The  numerous  gan- 
glia are  bathed  in  waste-laden  and  irritating  blood. 
Innumerable  local  and  distant  neurasthenic  conditions 
are  manifest.     We  have,  then,  as  a  train  of  evil  symp- 


Fig.  59.— Author's  perineorrhaphy  needle. 

toms  following  genital  defects:  1,  local  irritation — an 
infection  atrium;  2,  reflex  irritation  to  the  abdominal 
brain,  where  it  is  reorganized  and  sent  out  to  the 
various  viscera;  3,  indigestion  and  malnutrition;  4, 
anemia;  and  5,  neurosis. 

In  the  incomplete  cases  of  laceration  the  disturbance 
is  attributed  to  gaping  of  the  vulva  and  the  consequent 
favoring  of  rectocele  and  cystocele.  This  condition 
is  followed  by  uterine  prolapse,  endometritis  and  met- 
ritis. The  patient  suffers  from  ill-defined  pains  while 
standing  and  walking.  These  patients  complain  in  a 
manner  similar  to  that  of  those  who  are  afflicted  with 
enteroptosis.  When  the  lacerations  become  complete, 
not  only  a  physical  defect  of  control  of  feces  and  gas 
exists,  but  a  train  of  mental  symptoms  follow  com- 
plete lacerations  or  serious  lesions  and  gravely  affect 


HOW  TO   MEND   THEM.  129 

life,  both  physically  and  mentally.  The  patient  is 
easily  fatigued,  neurotic  constantly,  liable  to  exacer- 
bation of  infectious  processes. 

One  of  the  most  unfortunate  results  of  extensive 
laceration  of  the  rectovaginal  septum  is  diarrhea. 
When  the  sphincter  muscles  have  been  so  far  drawn 
apart  at  the  ends  that  they  are  almost  a  straight  line, 
the  rectum  has  lost  all  control  of  feces.  A  straight 
sphincter  is  a  symptom  of  complete  laceration;  the 
diarrhea  accompanying  the  straight  sphincter  is  very 
exhausting.  The  amount  of  separation  in  the  sphinc- 
ter muscle  tells  the  story  of  the  degree  of  laceration. 
When  one  can  find  the  deep  dimples  in  the  skin,  on 
each  side  of  the  gaping  vulva,  due  to  the  cicatricial 
ends  of  the  muscular  bundles  contracting,  it  may  be 
estimated  that  the  vaginal  sphincter  is  extremely  de- 
fective and  that  over  half  of  its  arc  is  wide  open. 
Only  a  carefully  planned  operation  can  relieve  this 
condition.  The  widely  gaping  vulva  is  exposed  to 
much  trauma  and  consequent  infectious  processes. 
The  congested  genitals  and  rectum  produce  excessive 
glandular  secretion,  which  furnishes  a  culture  medium 
not  only  to  the  pathogenic  bacteria,  but  tends  to  mul- 
tiply the  regular  residents  of  this  locality  into  exces- 
sive number,  and  in  all  probability  dangerous  kinds, 
for  doubtless  bacteria  rapidly  change  from  one  kind 
to  another  by  change  of  food  and  temperature.  It 
would  be  strange  indeed  if  all  the  scores  of  uterine 
tubular  glands  could  long  remain  normal  with  fre- 
quent congestions  and  decongestions.  Excessive  bac- 
teria in  any  locality  must  produce  their  dangerous 
toxins,  which  become  absorbed  and  carried  away  by 
the  veins  and  lymphatics.  The  rectal  veins  are  known 
to  stand  in  direct  communication  with  the  liver  by 
way  of  the  valveless  portal  system.  Hence  may  be 
observed  the  vicious  circle  established  by  the  defec- 
tive sphincter  apparatus  of  the  vagina.    Again,  con- 


130  THE  VAGINA  AND  PERINEUM 


sider  the  innumerable  reflexes  which  must  necessarily 
arise  from  the  infected,  frequently  congested,  occa- 
sionally acute,  inflammatory  invasions  of  the  genito- 
rectal  organs.  These  reflexes  arise  in  all  degrees  and 
conditions,  and  the  patient  almost  imperceptibly 
passes  through  the  stages  of  indigestion,  malnutri- 
tion, anemia  and  neurosis.  Again,  many  of  these 
patients  are  operated  on  by  inexperienced  surgeons, 
with  consequent  imperfect  results.  Then  a  conflict 
of  opinion  arises  as  to  the  perineal  defect  being  the 
cause  of  the  trouble  or  whether  the  etiology  is  to  be 
located  in  the  nervous  system,  for  one  of  the  evils  of 
today  is  the  confounding  of  nervous  and  genital  dis- 
eases. After  an  imperfect  operation  on  the  genitals, 
with  a  consequent  imperfect  result,  the  operator  is 
liable  to  throw  the  whole  defect  on  the  nervous  sys- 
tem. As  the  nervous  system  and  the  liver  are  the 
chief  scapegoats  of  ignorance  (and  knavery)  it  is 
difficult  to  demonstrate  the  error.  It  requires  wisdom, 
knowledge  and  experience  to  discriminate  between 
genital  diseases  and  their  consequent  train  of  neurotic 
effects,  and  the  diseases  which  definitely  belong  to  the 
nervous  system  itself  or  to  other  causes  than  the  gen- 
itals. I  must  insist,  however,  that  this  requires  more 
time  and  skill  than  any  general  surgeon  or  physician 
is  able  to  give. 

Until  one  comprehends  the  practical  anatomy,  it  is 
almost  impossible  to  interpret  the  rational  symptoms 
of  the  deficiency  of  the  supports  of  the  sexual  organs. 
The  popular  view  of  general  physicians  that  the  peri- 
neal body  is  the  chief  support  is  one  illusion  which 
I  find,  after  considerable  experience  in  teaching,  diffi- 
cult to  eradicate.  It  is  the  indefensible  mechanical 
theory  that  the  perineal  body  is  the  keystone,  the  cork 
which  stops  the  bottle,  or  the  wedge  which  plugs  up 
the  pelvic  outlet.  Unfortunately,  a  prominent  Ameri- 
can gjrnecologist  at  one  time  abetted  this  false  theory. 


HOW  TO   MEND   THEM/  .         131 

One  of  the  very  common  diseases  accompanying 
perineal  lacerations  is  endometritis.  Little  need  be 
said  to  defend  or  explain  this  condition,  for  it  is  evi- 
dent to  all  observers  how  the  endometrium  may  be 
insulted  by  trauma,  congestion  and  bacterial  invasion, 
when  unduly  exposed  from  deficient  support.  Exces- 
sive glandular  secretion  arises;  leucorrhea,  which  may 
be  non-infective,  then  pathogenic  infection  soon  fol- 
lows with  its  consequent  train  of  evils. 

This  leads  me  to  a  subject  of  vast  importance.  It 
is  the  metritis  (subinvolution)  which  so  frequently 
accompanies  laceration  of  the  perineum.  The  general 
practitioner  calls  it  subinvolution.  But  we  will  call 
it  metritis,  because  we  believe  it  to  be  of  microbic 
origin.  Be  it  remembered,  the  uterus  above  all  organs 
is  liable  to  infection,  because  its  glands  pass  directly 
into  its  muscular  walls.  It  has  no  submucous  layer 
or  barrier  to  protect  the  muscle.  The  intestine  has  a 
submucous  muscular  layer  which  acts  like  a  barrier 
against  microbe  invasion.  But  the  uterus  has  no 
muscularis  mucosae.  It  has  no  barrier  between  its 
glandular  apparatus  and  its  muscular  apparatus,  so 
that  microbes  or  their  products  which  gain  the  uterine 
glands  soon  gain  the  muscular  walls  of  the  uterus 
and  produce  metritis.  Hence  metritis  is  one  of  the 
frequent  accompaniments  of  perineal  laceration,  and 
as  metritis  is  a  very  chronic  disease,  it  is  apt  to  con- 
tinue even  beyond  the  repair  of  the  perineal  injury. 

From  this  short  view  it  may  be  observed  that  the 
rational  symptoms  of  injuries  to  the  pelvic  floor  are 
generally  a  train  of  evils  which  increase  with  time,  and 
the  final  brunt  is  most  apparent  in  the  nervous  sys- 
tem. Many  of  the  symptoms  can  only  be  accounted 
for  by  carefully  noting  the  many  cases  of  invisible 
lacerations — the  relaxed  pelvic  floors,  perineal  supports 
and  sphincter  vagina  apparatus — which  disturbes  cir- 
culation by  the  vessels  being  torn  from  their  proper 


132  THE   VAGINA  AND   PERINEUM; 

fascial  beds,  the  veins  becoming  elongated,  dilated, 
straight,  and  losing  their  normal  spiral  form,  and  the 
nerves  being  put  on  the  stretch  or  traumatized. 

We  thus  have  disturbed  vascularization;  conges- 
tions and  decongestions  of  blood  and  lymph  have  also 
disturbed  innervation  from  traumatized  nerves.  En- 
teroptosis  exists  and  the  avenues  of  infection  are 
widely  exposed.  The  supports  of  the  pelvic  floor  have 
been  overstretched  by  one  or  more  labors  and  have 
not  resumed  their  normal  integrity.  On  examining 
such  patients,  as  Schatz  points  out,  the  normal  anal 
cleft  is  flattened  out,  the  dent  and  furrow  becomes 
broad  and  shallow  and  the  anus,  instead  of  being 
drawn  up  under  the  pubic  arch,  appears  flat,  exposed, 
and  fallen  back  toward  the  coccyx.  The  skin  peri- 
neum may  be  much  larger  than  normal,  being  over- 
stretched. The  finger  introduced  into  the  vagina  no 
more  feels  the  rigid  levator  ani  muscle  loop,  but  in  its 
stead  the  relaxed,  overstretched,  flabby  tissues  lying 
between  the  gap  made  by  the  separation  of  the  leva- 
tor ani  fascia 'superior  and  inferior  with  its  contained 
muscle  in  various  degrees.  Perhaps  there  is  no  lesion 
more  overlooked  in  the  pelvic  floor  by  the  general 
practitioner  than  the  relaxed,  overstretched  outlet.  In 
1883  Emmet  and  Schatz  first"  clearly  announced  their 
views  in  regard  to  relaxed  pelvic  outlet.  The  very 
deep  perineum  is  deficient,  while  the  shallow,  short 
one  is  the  vigorous  one.  The  patient  with  relaxed 
pelvic  outlet  generally  begins  to  complain  of  bearing- 
down  symptoms  on  rising  from  bed  some  two  or  three 
weeks  after  labor.  She  feels  weak,  unable  to  work  or 
exert  herself,  pain  in  the  back,  general  lassitude  and 
prostration. 

The  relaxed  pelvic  floor  is  most  impressive  to  the 
operator,  by  examination  before  and  after  the  anes- 
thetic, when  he  is  about  to  operate.  Before  the  anes- 
thetic the  pelvic  outlet  is  held  in  partial  tension  by 


HOW   TO   MEND   THEM.  133 

the  remnants  of  the  muscular  and  fascial  supports; 
the  loops  of  the  levator  ani  muscle  being  irritated  by 
the  non-balance  of  parts  being  torn,  the  patient  is 
constantly  losing  nerve  force  by  the  attempts  of  the 
reflex  irritation  in  keeping  up  the  tension.  When  the 
patient  is  fully  anesthetized  the  parts  of  the  pelvic 
floor  show  vast  relaxation  and  it  becomes  at  once  ap- 
parent to  the  hand  and  eye  of  the  operator  that  a  sig- 
nificant defect  exists,  beyond  his  expectation,  in  the 
sexual  apparatus.  The  perineum  falls  back,  the  anus 
flattens  and  everts,  the  vaginal  walls  roll  outward,  and 
the  deep  anal  furrow  assumes  a  plane  approximating 
that  of  the  buttocks.  Vast  changes  in  subcutaneous 
and  submucous  supports  have  occurred,  capable  of 
being  repaired  only  by  an  operation  which  restores 
vessels  to  a  stable  bed,  nerves  to  a  protected  sheath, 
and  organs  to  a  position  which  will  insure  normal 
circulation  and  innervation — in  short,  proper  nour- 
ishment. With  such  patients  in  the  erect  posture  the 
intra-abdominal  pressure  is  continually  displacing  the 
viscera  by  forcing  them  into  and  through  the  weak- 
ened pelvic  outlet.  The  pelvic  outlet,  beyond  the 
normal  floor  is  full  of  prolapsing  organs  which  often 
deceive  the  practitioner  by  closing  up  the  gap. 

The  length  of  time  allowed  to  relapse  between  the 
injury  and  the  operation  on  the  perineum  should  not 
be  less  than  three  months.  The  parts  do  not  heal 
well  shortly  after  labor.  Old  gynecologists,  as  Byf ord, 
recommended  at  least  six  months  to  elapse  before  the 
operation  should  be  performed.  Perhaps  four  months 
after  injury  it  would  be  fairly  safe  to  operate.  The 
old  cicatrix  can  not  always  readily  be  found,  but  by 
pulling  on  the  vagina  in  various  directions  the  puck- 
ering tissue  about  the  scar  will  be  discovered.  The 
palpating  finger  may  also  find  it. 

The  cicatrix  produces  new  points  for  the  attach- 
ment of  the  torn  fibers  of  the  levator  ani  muscles 


134         THE  VAGINA  AND  PERINEUM; 

which  may  give  the  outlet  a  peculiar,  irregular,  puck- 
ered appearance  when  the  muscular  bundles  contract 
from  their  new  points  of  attachments.  The  flap  for- 
mation should  extend  beyond  the  cicatrices  so  that 
the  ends  of  the  muscular  bundles  may  be  included  in 
the  sutures.  The  time  for  operation  should  be  mid- 
way between  the  menstrual  periods. 

In  regard  to  the  perineal  body :  The  posterior  curve 
of  the  vagina  must  be  reproduced  by  restoring  the 
rectovaginal  septum. 

A  new  perineal  body  should  be  restored,  so  that  the 
natural  backward  curve  of  the  vagina  should  persist, 
i.e.,  normal  relations  should  be  established  between 
the  perineal  center  of  body  on  the  one  hand  and  fas- 
cia on  the  other.  The  perineal  body,  the  punotum 
fixum  of  vulvar  surface  relations,  should  be  restored. 

In  writing  this  essay  I  have  derived  aids  and  sug- 
gestions from  all  accessible  authors  and  have  at- 
tempted to  duly  credit  the  labors. 

Some  suggestions  were  acquired  in  regard  to  draw- 
ings from  the  book  of  W.  J.  Stewart  McKay. 


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